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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.
Effective for dates of service on or after October 1, 2020, telemonitoring benefits will change for Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- Additional benefits for clients who are 20 years of age and younger
- Updated documentation requirements
- Changes to prior authorization guidelines
- Revised prior authorization form
Benefits for Clients 20 Years of Age and Younger
In addition to the current conditions of diabetes and hypertension, home telemonitoring services will also be a benefit for clients who are 20 years of age and younger, with one or more of the following conditions:
- End-stage solid organ disease
- Organ transplant recipient
- Requiring mechanical ventilation
Documentation Requirement Updates
The client’s medical record must include data transmission information that demonstrates the use of monitoring equipment, such as the following:
- Date of transmission
- Frequency of transmission
- Clinical data provided to the client’s primary care physician, or his or her designee
The telemonitoring equipment must be capable of measuring and transmitting client weight, oxygen levels in blood, glucose levels in blood, and blood pressure data.
The registered nurse (RN), nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA) in a licensed home health agency or a hospital is responsible for reporting data to the prescribing physician. Scheduled periodic reporting of the client data to the physician is required at least once every 30 days.
Documentation supporting medical necessity for telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency or hospital) and is subject to retrospective review. All paid telemonitoring services not supported by documentation of medical necessity are subject to recoupment.
Prior Authorization Updates
Home telemonitoring services may be requested and approved for up to 180 days per prior authorization request.
The Home Telemonitoring Services Prior Authorization Request form must be signed and dated within 30 days before the start of care. An RN, NP, CNS, or PA may sign the prior authorization request form on behalf of the client's physician when the physician delegates this authority to the RN, NP, CNS, or PA. The RN, NP, CNS, or PA name, TPI or NPI, signature, and date must appear on the form.
If the prior authorization form is not signed and dated by the physician or an authorized delegate, the prior authorization request must be accompanied by a written order or prescription that is signed and dated by the physician, or a complete verbal order from the physician. A complete written order or verbal order must include all of the following:
- Physician ordered home telemonitoring transmission frequency.
- The client’s qualifying condition(s) and risk factors for home telemonitoring services.
- The ordered services including applicable procedure codes or descriptions.
- Dates of service matching or greater than those on the prior authorization request form.
- If prior authorization is being requested for the initial setup and installation, orders for initial requests must include the initial setup procedure code or description.
A request received without a physician’s or authorized delegate’s signature, documented verbal order, or written prescription will not be approved and may be denied.
Revised Prior Authorization Form
Effective October 1, 2020, the Home Telemonitoring Services Prior Authorization Request form will be updated as follows:
- Addition of qualifying conditions for clients who are 20 years of age and younger
- New section for specific details about the requested authorization period
The revised form will be available as a fillable PDF on the TMHP website beginning October 1, 2020. Providers may submit prior authorization requests for home telemonitoring services through the electronic prior authorization portal, fax, or mail.
Instructions for completing the Home Telemonitoring Services Prior Authorization Request form will also be available on the TMHP website beginning October 1, 2020.
The Home Telemonitoring Services Prior Authorization Request form (Revised: 02/01/2016 version) will no longer be accepted after October 31, 2020. If the discontinued form is submitted on or after November 1, 2020, TMHP will return the form to the provider with a request that the revised form be submitted.
Requests Submitted through Prior Authorization Portal
The Home Telemonitoring Services Prior Authorization Request form will be updated with the revised form that is effective October 1, 2020.
Instructions for completing the Home Telemonitoring Services Prior Authorization Request form will also be available on the prior authorization portal beginning October 1, 2020.
For more information, call the TMHP Contact Center at 800-925-9126.