Provider Alert! Prior Authorization Re-certification Requests Submission for Texas Medicaid

Date: January 7, 2021
Attention: Therapy Providers
Effective Date: October 1, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) aligns with the guidance on prior authorization (PA) recertification requests. In compliance with House Bill 3041 of the 86th Texas Legislature, a physician or health care provider may submit a medical PA recertification request at least 60 days prior to the expiration of the current PA of services.
Source: TMHP Notice

How this impacts providers: If practicable, the request must be reviewed and a determination issued prior to the expiration of the existing PA. For some services, it is not practicable to prior authorize a new course of treatment 60 days prior to the end of the current PA period. For example, it is not practicable to recertify private duty nursing (PDN) PAs 60 days prior to the end of the current PA. Such services require documentation, including assessments of client status and nursing or therapy notes more recent than 60 days prior to the end of the PA date.
Recertification requests are still subject to medical necessity determinations.

When a request is received that is not practicable for review 60 days prior to the PA expiration, TCHP must provide a response that includes why it is not appropriate to submit a recertification request outside of the timelines listed in the Texas Medicaid Provider Procedures Manual (TMPPM) or the MCO’s PA requirements for the particular service.

Next steps for providers: Providers should inform their staff of the guidance on PA recertification requests.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.