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Changes to the Sterilization Consent Form, Instructions, and Denial Letter Effective April 26, 2019

Last updated on 3/8/2019

Effective April 26, 2019, changes will be made to the Sterilization Consent Form, instructions, and denial letter. These changes will impact all providers that use the Sterilization Consent Form.

Sterilization Consent Form

The following changes will become effective April 26, 2019:

  • The font size will increase and the formatting will be updated. These changes will increase the number of pages in the consent form from 1 to 3.
  • An italicized letter “X,” will be added to indicate where a signature is required.
  • The Texas Provider Identifier (TPI) will no longer be required.
  • A free field text box will be added to the top right of the Sterilization Consent Form with a note indicating that TMHP will not be using this field for any processing of the consent form. This field is for the provider’s use only.
  • A reminder has been added to the instructions of the Sterilization Consent Form to check for accuracy and to refer the provider to the instructions page on the TMHP website.

Sterilization Consent Form Instructions

  • The instructions for the Sterilization Consent Form will incorporate instructions related to the free field text box for providers use only. This is an optional field for provider purposes and is not intended to be used by TMHP. The instructions will also indicate that TMHP will not use this field for processing of the consent form.
  • The asterisks for the TPI will be removed.

Current Sterilization Consent Form Submission Deadline

TMHP will continue to accept the current version of the Sterilization Consent Form through October 23, 2019 (180 days from April 26, 2019, the effective date).

Important: The new consent form is required on or after October 24, 2019. Any submissions of the previous version of the consent form will be denied.

838 Denial Letter

  • Fields 3 and 4 will be included in the corrections section for “Consent to Sterilization.”
    • Field 3 will indicate a “doctor or clinic”
    • Field 4 will indicate “specify type of operation”
  • Field 24 on the 838 denial letter will include two options:
    • Option 1 is to correct the “type of operation.”
    • Option 2 is for medical necessity.

Providers can use this to correct the type of operation or to include medical necessity. For example, “I ______ (physician’s name), certify that on the basis of my professional judgment _____ (procedure) was medically necessary because ______” and will include a physician’s signature.

  • Field 26 on the 838 letter will be updated to mirror the current options on the Sterilization Consent Form.
  • Field 26, option 2 on the 838 denial letter has instructions that an operative report needs to be submitted if an emergency abdominal surgery occurred. Beginning on April 26, 2019, the physician can describe the circumstances and provide a signature. The signature will be considered the attestation.

Other Documentation

Providers can refer to the previous article titled “Changes to the Sterilization Consent Form and Instructions, Approval Process, and Denial Letter,” that was published on this website on July 15, 2016, for more information about “other documentation.”

For more information, call the TMHP Contact Center at 800-925-9126.