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.
Providers that supply nutritional products, supplies, and equipment through the Medicaid Comprehensive Care Program (CCP), Medicaid Home Health (HH), and the Children with Special Health Care Needs (CSHCN) Services Program should understand the requirements for submitting requests and understand the intent for “total caloric intake prescribed by a physician.”
The following are the procedures for the process:
- For Medicaid clients who are 20 years of age and younger: formula, supplies, and equipment will be processed in CCP using the Nutritional Products – CCP Requirements.
- Prior Authorization staff will process requests with the understanding that “total caloric intake prescribed by physician” is from ALL sources.
- >Prior Authorization staff will not perform calculations to determine the “total caloric intake prescribed by physician.” The Prior Authorization staff will pend for this information as required per the Texas Medicaid Provider Procedures Manual and the CSHCN Services Program Provider Manual.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.