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Prior Authorization Requests Extended Due to COVID-19 Public Health Emergency

Last updated on 3/31/2020

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Information posted March 31, 2020

To help ensure continuity of care during the COVID-19 (coronavirus) response, the Health and Human Services Commission (HHSC) has directed TMHP to extend by 90 days existing prior authorizations (PAs) that require recertification and are set to expire March 13, 2020, through April 30, 2020.

The extended authorizations will contain the same proportional amount and frequency as was authorized in the original prior authorization.

This extension does not apply to current authorizations for one-time services or pharmacy PAs. For example, a single non-emergency ambulance trip would not be extended, but a recurrent non-emergency ambulance authorization for dialysis would be extended.

Providers will receive additional communication once the impacted prior authorizations have been extended. Any claims impacted by the PA extension will be automatically reprocessed.

A provider may submit an amended request to an existing, extended PA and TMHP will process the request and override the 90-day extension as appropriate. Requests for new PAs will be processed according to current guidelines and will not be subject to the 90-day extension at this time.

Providers can access TMHP Prior Authorization (PA) on the Portal from the TMHP Prior Authorization webpage to review the status of PAs. To learn more about checking PA status on PA on the Portal, providers can review section 4.0, “Status” of the PA on the Portal Submission Guide, which is located on the TMHP Learning Management System website.

Note: It is expected that before reimbursement is requested, providers have obtained the appropriate required documentation. The services delivered may still be subject to retrospective review for medical necessity. Exceptions will be reviewed on a provider or recipient-specific basis and need.

Direct questions to the TMHP Contact Center at 1-800-925-9126