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, the Health and Human Services Commission will allow TMHP to extend for 90 days existing prior authorization requests that are set to expire through December 31 2020, after which time the 90-day prior authorization extensions will end.
Note: Providers currently have an option to request prior authorization time periods other than the 90-day extension.
For new and initial prior authorization requests and for recertifications of existing prior authorizations, providers are referred to the TMHP Covid-19 webpage and the article "COVID-19 Guidance for New and Initial Prior Authorizations". For prior authorizations expiring on or after January 1, 2021, providers can utilize the flexibility offered under the above referenced guidance if they are unable to provide required documentation on a timely basis due to a COVID-19 related issue.
Providers will need to continue to alert TMHP of which option they wish to pursue. 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 1-800-925-9126 if they have questions or need other information about providing Texas Medicaid services. For recipients enrolled in managed care, providers should contact the MCO for additional guidance.