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 September 1, 2021, system changes are coming, and all prior authorization forms are being updated. New fields will be added to the forms.
Also, the Texas Provider Identifier (TPI) number will be removed from prior authorization forms that currently contain this identifier.
In place of the TPI, each prior authorization form must have the information that follows in the corresponding fields to initiate the prior authorization review process.
Essential and Critical Information fields will be clearly marked with an asterisk. Essential information is required for processing a prior authorization request. Prior Authorization Forms submitted with missing Essential/Critical Information will be returned to the provider.
Essential Information Fields: Essential Information required for processing a prior authorization request:
- Client/Member name
- Client/Member Medicaid number
- Client/Member date of birth
- Requesting provider name
- Requesting provider National Provider Identifier (NPI)
- Rendering provider name
- Rendering provider NPI
- Rendering provider Tax Identification Number (TIN)
- Service being requested – Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT)
- Service requested start and end dates
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
Critical Information Fields: Critical information specifically required by TMHP to process a prior authorization request:
- Rendering provider taxonomy code (classification, and/or specialization of health care providers)
- Rendering provider benefit code (if applicable)
- Rendering provider complete address with city, state, and ZIP+4 code in the appropriate fields, as per form instructions
Providers Should Stop Using TPIs by December 1, 2021
To promote a smooth transition as the TPI is phased out, TMHP will continue to accept older forms that include TPIs after September 1, 2021, until November 30, 2021. After this transition period ends, only the revised NPI/API-based forms will be accepted.
Important: Effective December 1, 2021, forms with TPIs will be returned, resulting in a delay in authorization approval or service reimbursement.
For more information, call the TMHP Contact Center at 800-925-9126.