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Reminder of Height and Weight Requirement for Home Health DME and Supplies Exceptional Circumstances Provision

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective June 1, 2020, nutritional product requests for clients who are 21 years of age or older that do not meet the criteria for coverage through Title XIX Home Health Services may be considered under the Texas Medicaid Home Health - Durable Medical Equipment (DME) and Supplies Exceptional Circumstances process.

Providers must record the client’s current height and weight. The current height and weight is defined as being recorded/dated within 90 days of the prior authorization submission. The current height and weight can be listed on the Title XIX DME/Medical Supplies Prescribing Provider Order Form or anywhere on the submitted documentation, although it’s preferred on the Title XIX form for easier access.

If a current height or weight is not provided, the prior authorization submission will be pended for missing information.

For additional information on exceptional circumstances, providers may refer to the Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, Section 2.2.3, “Home Health DME and Supplies Exceptional Circumstances Provision,” sub-section 2.2.3.1, “Prior Authorization Requests for Home Health DME and Supplies under the Exceptional Circumstances Provision.”

For more information, call the TMHP Contact Center at 800-925-9126.