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, HHSC will allow TMHP to extend existing prior authorization requests that are set to expire in August 2020 and until further notice, for 90 days, if providers are unavailable or unable to provide the required documentation on a timely basis due to a COVID-19 related issue.
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. TMHP may request additional information if it is deemed necessary but will not deny prior authorization requests if providers are unavailable or unable to provide required documentation on a timely basis.
It is expected that before reimbursement is requested, the provider has obtained the appropriate required documentation for inclusion in the client’s file. 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.
Fee-for-Service providers should contact the TMHP Contact Center at 800-925-9126 if they have questions or need other information about providing Texas Medicaid services.
For more information, call the TMHP Contact Center at 800-925-9126.