Determining Medical Necessity
PCHP uses the following resources to determine medical necessity:
- Texas Medicaid Provider Procedures Manual
- InterQual® Criteria Products: Adult and Pediatric (Level of Care: Acute Criteria), Inpatient Rehabilitation (Level of Care), Subacute/SNF (Level of Care), Home Care Q&A (Level of Care), (Level of Care) Outpatient Rehabilitation & Chiropractic, Procedures, Imaging, Specialty Rx Oncology, Specialty Rx Non-Oncology, Molecular Diagnostics, Durable Medical Equipment
- American College of Obstetricians and Gynecologists (ACOG) Guidelines
PCHP may request any combination from the following list of clinical information to support medical necessity of requested services. All information and documents should be current and legible with appropriate ordering physician signature dated within the allowable timeframe per TMPPM.
Information and documents should relate to the current request for physical health services. In addition to the applicable documents listed below:
Inpatient / Observation
- Admission Notification and/or Face Sheet
- Discharge Summary
- Diagnosis
- History and Physical
- Clinical / Progress Notes that support medical necessity
- Consult Notes and/or Reports from Specialists
- Signed Physician Orders
- Radiology/Imaging Results
- Laboratory Results
Outpatient
- Rendering Provider’s Name, NPI number, and TAX ID
- An explanation of Medical Necessity or Reason for Referral to Out-of-Network Provider
- Modifiers
- Prior Authorization Form
- Signed Physician Orders
- Change of Provider Letter
- Diagnosis
- History and Physical
- Overall Health Status
- Clinical/Progress Notes that support medical necessity
- Plan of Care
- Consult Notes and/or Reports from Specialists
- Radiology/Imagining Results
- Laboratory Results
- Blood Glucose Testing
- Vital Sign Reports
- Medication Administration Records or Medication History
- Developmental Screening Tool
- Hearing evaluations and test results
- Growth History and Growth Charts
- Height, Weight, BMI
- Seating Assessments
- Underlying causes for failure to thrive, lack of growth and/or failure to gain weight
- The reason why the member cannot be maintained on an age-appropriate diet including high calorie snacks/food
- Notes from current pregnancy
The above is not an exhaustive list. Please refer to the Texas Medicaid Provider Procedures Manual for a complete list of required clinical element per service being requested.
Exceptional Circumstances: Requesting Services over the benefit limit or noncovered benefits.
When requesting authorization for court-ordered care, providers must submit a copy of the court order to PCHP. If a court order is not received, PCHP will process the request using appropriate medical necessity criteria.
- Texas Standard Prior Authorization Request Form (TSAF) or Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form signed and dated by the requesting provider with notation indicating the request is submitted for services over the benefit limit or for a noncovered benefit.
- The member’s specific diagnosis, medical need, and the reason why the medical need can only be met by the requested services.
- A description from the member’s requesting provider or other clinical professionals, as appropriate, either in a letter or office note, documenting the alternative measures, equipment, or supplies that have been tried and have failed to meet the member’s medical needs, or have been ruled out and an explanation of why they have failed or have been ruled out.
- The manufacturer’s suggested retail price (MSRP) for the requested DME or supply or an invoice documenting the provider’s cost when the item price is not listed on the TMHP fee schedule.