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 (HHSC) has directed TMHP to move forward with processing new and initial prior authorization requests, including recertification requests, by relaxing document submission timeframes for providers if they are unable to provide certain required documentation during the COVID-19 emergency. This direction will remain in effect through December 31, 2021.
Beginning with dates of service January 1, 2022 and after, all pre-COVID prior authorization timeframe and submission requirements will resume as outlined in the Texas Medicaid Provider Procedures Manual (TMPPM). COVID flexibilities will no longer apply after December 31, 2021. Providers may refer to TMPPM Volume 1, Fee-for-Service Prior Authorizations, Section 5.4, “Submitting Prior Authorization Forms,” to review prior authorization timeframe and submission requirements for prior authorizations submitted after December 31, 2021.
This guidance applies to all state plan services, including:
- Acute care services
- Long-term services and supports
- Personal assistance services
- Personal care services
- Community First Choice
- Private duty nursing
- Day activity and health services
- Durable medical equipment and supplies
Examples of such documentation include, but are not limited to:
- Texas Medicaid Provider Procedures Manual-required timely signatures from physicians and other providers
- Client signatures
- Up-to-date visit with primary care or ordering physician
- Certification of timely face-to-face visits
Providers must submit the appropriate prior authorization forms for requesting services, and include the following information:
- Diagnosis codes
- Applicable modifiers
- Dates of service
- Quantities for each service requested
Forms must be submitted in a timely manner, complete to the greatest extent possible, and documentation must note the COVID-19 related issues that prevent the provider from being able to submit required documents. Medical necessity-related documentation of clinical records to demonstrate patient status and progress specific to some services is still required. Such documentation includes, but is not limited to:
- Letters of medical necessity
- Therapy evaluations and re-evaluations
- Nursing plans of care and notes
- Seating assessments
Important: Failure to provide medical necessity-related documentation without a COVID-19 related explanation in the prior authorization request is justification for denial of the requested service due to an inability to determine medical necessity.
TMHP may request additional information if deemed necessary, but may not deny prior authorization requests if providers are unable to provide certain required documentation in a timely manner as outlined above. It is expected that before reimbursement is requested, the provider has obtained the appropriate required documentation for inclusion in the client’s file and will make it available upon retrospective review. The services delivered may still be subject to retrospective review for medical necessity-related documentation. TMHP should review exceptions on a provider- or recipient-specific basis.
For more information, call the TMHP Contact Center at 800-925-9126.