The form has been revised as follows:

·         It provides more detailed instructions for submitting the form.

·         Request Type subsections “New Request” and “Update Request” have been revised.

·         A new field has been added to identify the Prior Authorization Number (PAN) of a request to be updated.

·         Section 1 has been revised to include client, facility, and physician information.

·         A revised section 2 labeled “Request Information” to be completed for all requests.

Providers may submit authorization requests on either the new or the old form until December 31, 2009. Effective January 1, 2010, however, only the revised form will be accepted.

Click here to view the revised form.

For more information, call the TMHP Contact Center at 1-800-925-9126.