This article has been updated. To view the updated information, click here.
This is an update to the article titled “Guidance for Providers Regarding New and initial Prior Authorizations,” published September 30, 2021 on this website.
To help ensure continuity of care during the COVID-19 (coronavirus) response, the Texas Health and Human Services Commission (HHSC) has directed the Texas Medicaid & Healthcare Partnership (TMHP) to move forward with processing new and initial prior authorization requests, including recertification requests, by relaxing document submission timeframes for providers that cannot provide certain required documentation during the COVID-19 emergency.
This direction will remain in effect through December 31, 2021. This guidance applies to all Children with Special Health Care Needs (CSHCN) Services Program services requiring prior authorization.
Examples of such documentation include, but are not limited to:
- CSHCN Services Program Provider 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, completed to the greatest extent possible, and documentation must note the COVID-19 related issues that prevent the provider from submitting 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 cannot 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 will review exceptions on a provider- or recipient-specific basis.
Providers may refer to the CSHCN Services Program Provider Manual Chapter 4, “Prior Authorizations and Authorizations,” for more information about required authorization documentation.
For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.