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.
Beginning August 1, 2019, TMHP will update the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Section 4.5.6, “Frequently Asked Questions About Dental Claims.”
Within the subsection titled “Claim Submission Reminders,” two additions will be made:
- The following text will be added to the paragraph on general anesthesia: for clients who are 7 through 20 years of age
The revised paragraph is as follows:
General anesthesia (provided in the dentist office, ambulatory service clinic, and inpatient/outpatient hospital settings) does not require prior authorization for clients who are 7 through 20 years of age, unless the client does not meet the minimum required points for general anesthesia in Criteria for Dental Therapy Under General Anesthesia on the TMHP website at www.tmhp.com.
- The following information will also be added:
Prior authorization is required for clients who are 7 through 20 years of age that are in need of general anesthesia and do not meet the Criteria for Dental Therapy Under General Anesthesia requirements (22 point threshold). Prior authorization is required for medically necessary dental general anesthesia that exceeds once per six months, per client, any provider. The dentist providing therapeutic services under general anesthesia is responsible for obtaining prior authorization for both services.
For more information, call the TMHP Contact Center at 800-925-9126.