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Providers are Required to Fax Client Prior Authorization Requests Separately

Last updated on 7/18/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Faxing a Prior Authorization Request

If a provider is faxing prior authorization requests for more than one client, each client request must be faxed individually with a separate cover sheet. Requests received with multiple clients will be returned to the provider for resubmission to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance.

Providers must fill out essential fields on prior authorization forms completely and correctly to avoid unnecessary denials or delays. Essential fields contain information needed to process a prior authorization request and include the following:

  • Client name
  • Client Medicaid number (patient control number [PCN]) or Client Children with Special Health Care Needs (CSHCN) Services Program number
  • Client date of birth
  • Provider name
  • Texas Provider Identifier (TPI)/CSHCN TPI
  • National Provider Identifier (NPI)
  • Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code
  • Quantity of service units requested based on CPT or HCPCS code requested

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Prior Authorization Handbook, section 5.4 “Submitting Prior Authorization Forms” or the current CSHCN Services Program Provider Manual, Prior Authorizations and Authorizations Handbook, section 4.3.5 “How to Submit a Prior Authorization Request.”

Note: The faxed cover sheet is not meant to replace the appropriate prior authorization form. Providers cannot include information on a cover sheet needed to complete the review of a request. Prior authorization cover sheets must not contain any protected health information (PHI) per HIPAA.

Reminder: Providers need to include the corresponding reference number on the prior authorization fax cover sheet to ensure that the information is attached to the correct request.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Prior Authorization Handbook, section 5.5.2.2, “TMHP Prior Authorization Requests by Fax” or the current CSHCN Services Program Provider Manual, Prior Authorizations and Authorizations Handbook, section 4.3.10 “Sending Prior Authorization Requests via Fax.”

Prior Authorization Form Alterations

Providers needing to make a change to information on a prior authorization request form must strike through the incorrect information with a single line. The original content must remain legible, and the change must be initialed and dated by the original signatory or ordering physician when applicable. Changes that have been made using a correction fluid (e.g. Wite-Out) will not be accepted.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Prior Authorization Handbook, section 5.4, “Submitting Prior Authorization Forms” or the current CSHCN Services Program Provider Manual, Prior Authorizations and Authorizations Handbook, section 4.3.5 “How to Submit a Prior Authorization Request.”

Prior Authorization on the Portal

Providers that submit prior authorization requests online using Prior Authorization (PA) on the Portal need to follow the instructions for submitting requests found in the Texas Medicaid & Healthcare Partnership Prior Authorization (PA) on the Portal Submission Guide.

For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.