This article has been updated. Click here to see the update.
Information posted April 9, 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.
This is an update to the article titled, “Prior Authorization Requests Extended Due to COVID-19 Public Health Emergency,” which was posted on this website on March 31, 2020.
The update is that the extended prior authorizations (PAs) have been expanded to include PAs due for recertification between March 1, 2020, through May 31, 2020. To help ensure continuity of care during the COVID-19 (coronavirus) response, the Health and Human Services Commission (HHSC) has directed TMHP to extend existing PAs for 90 days.
The extended authorizations will contain the same proportional amount and frequency previously authorized. This extension does not apply to current authorizations for one-time services or pharmacy PAs. For example, a single nonemergency ambulance trip would not be extended, but a recurrent non-emergency ambulance authorization for dialysis would be extended.
Any claims impacted by the PA extension will be automatically reprocessed.
A provider may submit an amended request to an existing, extended PA and TMHP will process the request and override the 90-day extension with required documentation. Requests for new PAs will be processed according to current guidelines and will not be subject to the 90-day extension at this time.
Providers can access TMHP Prior Authorization (PA) on the Portal from the TMHP Prior Authorization webpage to review the status of their PAs. To learn more about checking PA status on PA on the Portal, providers can review section 4.0, “Status” of the PA on the Portal Submission Guide which is located on the TMHP Learning Management System website.
Note: It is expected that before reimbursement is requested, providers have obtained the appropriate required documentation. The services delivered may still be subject to retrospective review for medical necessity. Exceptions will be reviewed on a provider or recipient-specific basis and need.
For more information, call the TMHP Contact Center at 800-925-9126