Information posted June 26, 2020
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.
Reminder: When submitting a prior authorization request, a separate prior authorization form must be completed for each request for each client. Requests received for multiple clients will be returned to the provider for resubmission to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance.
Providers faxing prior authorization requests for more than one client must fax each client request individually with a separate cover sheet.
Note: The faxed cover sheet is not meant to replace the appropriate prior authorization form. Providers cannot include information on a cover sheet needed to complete the review of a request. Prior authorization cover sheets must not contain any protected health information (PHI) per HIPAA.
Reminder: Providers must include the corresponding reference number on the prior authorization fax cover sheet to ensure that the information is attached to the correct request.
Information must match throughout all pages of the corresponding prior authorization forms.
Supplemental documentation submitted with prior authorization forms must also match the client information listed on the prior authorization form.
TMHP will use the following Client Name Verification process to verify that the submitted prior authorization form is for the correct client:
- The first initial of the client’s first name on the prior authorization form must match the same information in the TMHP system.
- The first five letters of the client’s last name on the prior authorization form must match the same information in the TMHP system.
- The client’s Medicaid number on the prior authorization form must match the client’s Medicaid number in the TMHP system.
- The client’s date of birth on the prior authorization form must match the date of birth in the TMHP system.
Note: The client name order on the prior authorization form must match the name order in the TMHP system. When the form does not provide an order in which the name should be written, the name will be read from left to right; if there is no comma, it will be presumed that the first name is written first.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.