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RULE §363.211Service Authorization

(a) Authorization is required for payment of services. The provider must submit a complete request for prior authorization in order to be considered by HHSC for reimbursement. Prior authorization is a condition for reimbursement, but not a guarantee of payment.

(b) Only those services that HHSC determines to be medically necessary and appropriate are authorized.

(c) PPECC services are prior authorized with reasonable promptness. Prior authorization determinations are completed by HHSC within three business days of receipt of a complete request.

(d) Initial authorization may not exceed 90 days from the start of care. Following the initial authorization, no authorization for payment of PPECC services may be issued for a single service period exceeding 180 days. In addition, specific authorizations may be limited to a time period less than the established maximum based on factors such as the stability and predictability of the participant's medical condition.

(e) HHSC may deny or reduce the PPECC services when:

  (1) the participant does not meet the medical necessity criteria for admission;

  (2) the participant does not have an ordering physician;

  (3) the participant is not 20 years of age or younger;

  (4) the services requested are not covered under this subchapter;

  (5) the participant's needs are not beyond the scope of services available through Medicaid Title XIX Home Health Skilled Nursing or Home Health Aide Services, because the needs can be met on a part-time or intermittent basis through a visiting nurse as described by Chapter 354, Subchapter A, Division 3 of this title (relating to Medicaid Home Health Services);

  (6) there is a duplication of services;

  (7) the services are primarily respite care or child care;

  (8) the services are provided for the sole purpose of responsible adult training;

  (9) the request is incomplete;

  (10) the information in the request is inconsistent; or

  (11) the requested services are not nursing services as defined by the Texas Occupations Code Chapter 301 and its implementing regulations.

(f) All authorization requests, including initial authorization and authorization of extensions or revisions to an existing authorization, must be submitted in writing.

(g) Initial authorization requests for PPECC services must include the following documentation, which adheres to requirements in the Texas Medicaid Provider Procedures Manual:

  (1) physician order for services (a physician signature on the PPECC plan of care serves as a physician order for authorization purposes);

  (2) a plan of care developed by the PPECC in compliance with §363.209(a)(1) of this subchapter (relating to Benefits and Limitations);

  (3) all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual, or MCO forms if they contain comparable content; and

  (4) signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include an acknowledgement by the participant or the participant's responsible adult that he or she has been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care, must also be obtained.

(h) Required documentation for recertification of PPECC service authorization after the initial authorization or after an authorization period ends includes the same documents required for an initial authorization, as set forth in subsection (g) of this section.

(i) Revisions during an existing authorization period may be requested at any time, if medically necessary. Revision requests must include the same documentation required for an initial request, as set forth in subsection (g) of this section.

(j) If inadequate or incomplete information is provided, HHSC requests additional documentation from the provider to enable HHSC to make a decision on the request.

(k) During the authorization process, providers are required to deliver the requested services from the start of care date.

(l) Providers are responsible for a safe transition of services when the authorization decision is a denial or reduction in the PPECC services being delivered.

(m) A nursing assessment must be completed, signed and dated by a PPECC RN no earlier than three business days before the initial start of care. A nursing assessment is also required when there are changes in the participant's medical condition that impact the amount or duration of services, and for recertification. The nursing assessment is used to establish the participant's plan of care, and must contain the elements identified in the Texas Medicaid Provider Procedures Manual.

Source Note: The provisions of this §363.211 adopted to be effective November 1, 2016, 41 TexReg 8284

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