For fee-for-service and Primary Care Case Management claims, Texas Medicaid requires prior authorization for outpatient diagnostic radiology services, including computed tomography, magnetic resonance, positron emission tomography, and cardiac nuclear imaging.

Submit your request to  MedSolutions , using this Radiology Prior Authorization Request Form ( PDF ) for dates of service on or after Feb. 1, 2010. This form is available on the Texas Medicaid & Healthcare Partnership (TMHP) Web site under "Provider Forms." Access to the MedSolutions online prior authorization portal also is available from www.tmhp.com . Or, you may submit requests by phone at (800) 572-2116, fax at (800) 572-2119, or mail at Texas Medicaid & Healthcare Partnership, 730 Cool Springs Blvd., Ste. 800, Franklin, TN 37067. 

MedSolutions evaluates authorization requests using nationally accepted guidelines and radiology protocols that are based on the medical literature and reviewed annually by Texas physicians. You can use these public documents, found in the  Medicaid Radiology Guideline Library , help determine the most appropriate imaging procedure for each patient at the most appropriate time during the diagnostic and treatment cycle.  

When the requested study is not the most clinically appropriate study, MedSolutions may offer a different study when an alternate is available. When an authorization request has been denied, you may request a physician consultation with a MedSolutions medical director at (800) 572-2116. The consultations are scheduled at the convenience of the practicing physician.Both the physician ordering the test and the facility performing the study should maintain in the patient's medical record documentation supporting the medical necessity of the imaging study.

Note the following special situations.

Urgent or Emergent Situations

For urgent or emergent situations, physicians may request retroactive authorization. Use this chart for guidance:

Outpatient emergent and urgent studies also may be prior authorized if you submit them by phone to ensure a timely response. Note also:

• You must submit the retroactive authorization request within 14 calendar days after the day on which the study was completed.
• MedSolutions accepts retroactive authorization requests by phone, fax, or mail but not online. 
• Either the physician or the facility with the available clinical information to justify the request may submit the request.
• In the absence of an authorization, Medicaid will deny payment for both the technical and professional interpretation components.

Changes to Previously Authorized Procedures

Retroactive authorization is not required when the ordering physician or radiologist changes a previously authorized procedure to a lesser procedure of the same imaging technology (e.g., a physician receives prior authorization to perform an MRI with contrast but actually performs an MRI without contrast). Use this chart for guidance:

* Important: The authorization number must be on the claim when it is submitted to TMHP for payment. Only one authorization is allowed per claim. For the most accurate and efficient claims processing, TMHP recommends that the procedure code submitted on the claim match the procedure code that was authorized. You are encouraged to contact TMHP and update the prior authorization if the ordering physician or radiologist changes the actual procedure performed. You have seven calendar days after the procedure is performed to update the prior authorization.

A facility or radiologist may contact the MedSolutions radiology prior-authorization department to request an upgraded procedure or add a procedure to an existing prior authorization; the patient's primary physician does not need to submit the updated request.

For more information, call the TMHP Contact Center at (800) 925-9126.

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