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Guidance for Providers regarding New and Initial Prior Authorizations

Last updated on 7/2/2020

Information posted July 2, 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.

To help ensure continuity of care during the COVID-19 (coronavirus) response, the Health and Human Services Commission (HHSC) has directed TMHP to move forward with processing new and initial prior authorization requests, including recertification requests, by relaxing document submission timeframes for providers if they are unable to provide certain required documentation during the COVID-19 emergency. This guidance applies to all Children with Special Health Care Needs (CSHCN) Services Program services requiring prior authorization.

Examples of such documentation include, but are not limited to:

  • Required timely signatures from physicians and other providers
  • Client signatures
  • Up-to-date visit with primary care or ordering physician
  • Certification of timely face-to-face visits

Providers must submit the appropriate prior authorization forms for requesting services and include the following information:

  • Procedure codes
  • Diagnosis codes
  • Applicable modifiers
  • Dates of service
  • Numerical quantities for services requested

Forms must be submitted in a timely manner, complete to the greatest extent possible, and documentation must note the COVID-19 related issue(s) that prevent the provider from being able to submit the required documents. Medical necessity-related documentation of clinical records to demonstrate patient status and progress specific to some services is still required. Such documentation includes, but is not limited to:

  • Letters of medical necessity
  • Therapy evaluations and re-evaluations
  • Nursing plans of care and notes
  • Seating assessments

Important: Failure to provide this documentation without a COVID-19 related explanation in the PA request is justification for denial of the requested service due to an inability to determine medical necessity.

TMHP may request additional information if deemed necessary but may not deny prior authorization requests if providers are unable to provide certain required documentation in a timely manner as outlined above. It is expected that before reimbursement is requested, the provider has obtained the appropriate required documentation for inclusion in the client’s file and will make it available upon retrospective review. Exceptions will be reviewed on a provider or recipient-specific basis.

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