On 12/12/2014, the Texas Department of Insurance (TDI) published a mandate that all Medicaid MCOs in Texas use a released standardized prior authorization form starting 9/1/2015. This movement should bring about the standardization of information across all Medicaid MCO prior authorizations.
What this means for all Texas therapy providers: Required information will be universalized across all Texas managed Medicaid prior authorizations starting on 9/1/2015. The days of varying and inconsistent information that is needed across the spectrum of all Texas managed Medicaid MCO prior authorizations, are numbered. This should facilitate a standard way of requesting all prior authorizations, regardless of managed Medicaid MCO. Note, however, that an MCO could vary in the amount and types of supporting documents that they may request of the therapy provider. For example, one MCO may ask for evidence of medical necessity and plans of care included in evaluations, past treatment notes (SOAP notes), etc., while another MCO may ask for fewer clinical notes or a longer stretch of notes in the client’s clinical records with that therapy provider. Supporting documents should support some piece of information that is included in the standardized prior authorization form. MCOs may also vary in their average turnaround time for a disposition on prior authorizations to treat. However, MCOs that enter into a contract with the Texas HHSC must abide by their rules for managed Medicaid administrators. One of the rules is to inform a networked provider within a certain period of time from the date of a request for authorization to treat, of their disposition on that request. See http://www.kslaw.com/library/newsletters/HealthHeadlines/2015/0105/article4.html for more details.
Senate Bill 1216 (SB 1216) from the 2013 Legislative session put forth the requirement that all prior authorization information be standardized by 9/1/2015. The form can be found here http://www.tdi.texas.gov/rules/2014/documents/nofr001.pdf. Instructions for the form can be found here https://www.tdi.state.tx.us/rules/documents/pa1214.pdf.