In compliance with House Bill 3041, 86th Texas Legislature, Regular Session, 2019, a physician or health care provider can submit a medical prior authorization recertification request up to 60 days before the expiration of the current authorization of services. Once submitted, the recertification request will be reviewed, and a determination will be issued before the existing authorization ends.
For some services, a prior authorization recertification for a course of treatment cannot be issued 60 days before the end of the current authorization period. For example, physical therapy, occupational therapy, speech therapy, and private duty nursing prior authorizations cannot be recertified 60 days before the end of the current authorization period because of requirements for timely documentation. This limitation applies to both fee-for-service and managed care clients.
When a recertification request cannot be reviewed 60 days before the current prior authorization ends, the provider will receive a response from TMHP explaining that the request has been submitted too early, and the provider will need to resubmit the request. For managed care clients, providers should contact the client’s specific Managed Care Organization for details.
Providers can refer to the Texas Medicaid Provider Procedures Manual (TMPPM), section 5, “Fee-For-Service Prior Authorizations,” for more information about the prior authorization process. For information about prior authorization requirements for specific services, providers should refer to the TMPPM handbook for that service.
For more information, call the TMHP Contact Center at 800-925-9126.