|(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
(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
(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
(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;
(11) the requested services are not nursing services
as defined by the Texas Occupations Code Chapter 301 and its implementing
(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
(2) a plan of care developed by the PPECC in compliance
with §363.209(a)(1) of this subchapter (relating to Benefits
(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
(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