1 Tex. Admin. Code § 363.211 - Service Authorization

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

(b) HHSC only authorizes those services that HHSC determines to be medically necessary and appropriate.

(c) HHSC prior authorizes PPECC services with reasonable promptness. HHSC completes prior authorization requests for PPECC services within three business days of receipt of a complete request.

(d) Initial authorization may not exceed 90 calendar 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 calendar 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 Texas Medicaid 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 intended to provide respite care or child care;

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

(9) the prior authorization request is incomplete;

(10) the information in the prior authorization 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 Medicaid managed care organization forms if they contain comparable content; and

(4) signed consent of the participant or participant's responsible adult, that includes:

(A) documentation that the participant or participant's responsible adult chose PPECC services;

(B) acknowledgement by the participant or the participant's responsible adult that the PPECC informed the participant or participant's responsible adult that other services such as private duty nursing might be reduced as a result of accepting PPECC services; and

(C) the participant's or participant's responsible adult's consent for the PPECC to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care.

(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 PPECC to enable HHSC to make a decision on the request.

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

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

(m) A comprehensive nursing assessment must be completed, signed and dated by a PPECC registered nurse no earlier than three business days before the initial start of care and no later than the day the participant is admitted to the center. A nursing assessment is also required for a revision when there are changes in the participant's medical condition that impact the amount or duration of services during an existing authorization period, and for recertification of PPECC service authorization. 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.

Notes

1 Tex. Admin. Code § 363.211

Adopted by Texas Register, Volume 41, Number 43, October 21, 2016, TexReg 8284, eff. 11/1/2016; Amended by Texas Register, Volume 50, Number 07, February 14, 2025, TexReg 0831, eff. 2/19/2025