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Expendable Medical Supplies Request Forms for the CSHCN Services Program

Last updated on 12/13/2019

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.

Prior authorization for incontinence supplies (diapers, pull-ups, briefs, or liners) outside of allowable quantity limitations or for non-covered diagnoses in medical policy must be submitted on the CSHCN Services Program prior authorization form:

Prior authorization for all other expendable medical supplies outside of allowable quantity limitations must be submitted on one of the following CSHCN Services Program prior authorization forms:

Providers must fill out all sections of the prior authorization form. Providers should also refer to both of the following documents:

  • The Instructions page with each request form
  • Chapters 4 and 18 of the CSHCN Services Program Provider Manual (for complete information on prior authorization requirements).

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