The Texas Medicaid TP 1 form, officially known as the CSHCN Services Program Authorization Request for Initial Outpatient Therapy, is essential for obtaining authorization for various therapy services. This form must be completed accurately to ensure that claims are processed without delays or denials. To initiate the process, fill out the form by clicking the button below.
When filling out the Texas Medicaid TP 1 form, it's crucial to ensure accuracy and completeness. Here’s a guide on what to do and what to avoid:
Following these guidelines will help streamline the process and improve the chances of your authorization request being approved.
CSHCN Services Program Authorization Request for
Initial Outpatient Therapy (TP1) Form and Instructions
General Information
•Ensure the most recent version of the Authorization Request for Initial Outpatient Therapy (TP1) form is submitted. The form is available on the TMHP website at www.tmhp.com.
•Complete all sections of this form.
•Incomplete authorization requests will cause the claim to be denied.
•Print or type all information.
•Contact the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000, option 2, Monday through Friday, from 7 a.m. to 7 p.m., Central Time, for assistance with this form.
•This form may be submitted by mail to the following address:
TMHP-CSHCN Services Program Authorization Department
12357-B Riata Trace Parkway Ste #100 MC-A11
Austin, TX 78727
•This form may be submitted by fax to 1-512-514-4222.
•Submit only the authorization form. Do not submit instruction pages.
•Refer to: Chapter 30, “Physical Medicine and Rehabilitation” and Chapter 36, “Speech-Language Pathology (SLP) Services.”
Client Information
Field Description
Guidelines
First name
Enter the client’s first name as indicated on the CSHCN Services
Program eligibility form
Last name
Enter the client’s last name as indicated on the CSHCN Services
CSHCN Services Program
Enter the client’s ID number as indicated on the CSHCN Services
number
Date of birth
Enter the client’s date of birth as indicated on the CSHCN Services
Address/City/ZIP
Enter the client’s address, city, and ZIP
Diagnosis
Enter the diagnosis code relevant to the client’s condition.
Evaluation Summary
Date of evaluation
Enter the date of evaluation.
Note: A copy of the initial evaluation must be attached.
Type of evaluation
Check the appropriate type of evaluation
Comments
Service Request
Service request
Indicate procedure code(s), modifier, the dates of service, and the
frequency per week or month. Dates of service cannot exceed six
months. If possible, end requested date(s) of service on the last day
of a month.
Physician name, signature,
Indicate the prescribing physician’s name, signature, and date of
and date
signature
PT name, signature, and date
Indicate the physical therapist’s name, signature, and date of
OT name, signature, and date
Indicate the occupational therapist’s name, signature, and date of
F00009
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Effective Date_03172014/Revised Date_05202014
SLP name, signature, and date
Indicate the speech language pathologist’s name, signature, and
date of signature
Provider Information and Required Signature
Provider name
Enter the provider’s name
CSHCN TPI
Enter the provider’s Texas provider identifier (TPI)
NPI
Enter the provider’s national provider identifier (NPI)
Taxonomy code
Enter the provider’s taxonomy code
Benefit code
Enter CSN
Provider contact name
Enter the provider’s contact name
Telephone number
Enter the provider’s telephone number
Fax number
Enter the provider’s fax number
Enter the provider’s address, city, and ZIP
Provider signature
Provider must sign in this field
Date
Enter the date the form is signed
Additional Requirements
•The GP or the GO modifier is required when requesting authorization for PT and OT services. PT should be requested using the GP modifier and OT should be requested using the GO modifier
•SLP services should be requested using the GN modifier
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CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)
Please print or type requested information below.
First name:
Last name:
CSHCN Services Program number: 9-
-00
Date of birth:
Address/City/ZIP:
Diagnoses:
Evaluation Summary:
Date of evaluation:
(A copy of the initial evaluation must be attached.)
Type of evaluation: □ Physical Therapy (PT)
□ Occupational Therapy (OT) □ Speech Language Pathology (SLP)
Comments:
Service Request:
Indicate procedure code(s), modifier, the dates of service, and the frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.
Procedure Code
Modifier
From Date
To Date
Frequency/Week
Frequency/Month
Physician name:
Physician signature:
Date:
PT name:
PT signature:
OT name:
OT signature:
SLP name:
SLP signature:
Provider Information and Required Signature:
Provider name:
CSHCN TPI:
NPI:
Taxonomy code:
Benefit code: CSN
Provider contact name:
Telephone number:
Fax number:
Signature of provider:
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When submitting the Texas Medicaid TP 1 form for authorization of outpatient therapy services, several other forms and documents may be necessary to ensure a smooth process. Each of these documents plays a vital role in the overall authorization and payment process, contributing to the comprehensive assessment of the client's needs. Below is a list of commonly used forms and documents that accompany the TP 1 form.
In summary, the Texas Medicaid TP 1 form is an essential component of the authorization process for outpatient therapy services. However, it is often accompanied by several other documents that provide necessary context and support for the request. Ensuring that all forms are completed accurately and submitted together can significantly enhance the likelihood of approval.
Filling out the Texas Medicaid TP 1 form can be straightforward, but many people make common mistakes that can lead to delays or denials. One major error is submitting an outdated version of the form. Always ensure that you have the most recent version, which can be found on the TMHP website. Using an old form can result in immediate rejection of your request.
Another frequent mistake is leaving sections incomplete. Every part of the form must be filled out. If any information is missing, the authorization request will be denied. It’s essential to double-check that all required fields are completed before submission.
Many individuals also overlook the importance of clear and legible handwriting. Whether you print or type, ensure that all information is easy to read. Illegible forms can cause confusion and lead to processing delays.
People often forget to attach necessary documentation, such as the initial evaluation report. This report is crucial for the authorization request. Without it, the request may be rejected outright. Always include this documentation when submitting the form.
Another mistake is not specifying the correct procedure codes and modifiers. Each service request must include accurate codes, as well as the frequency of services. Errors in this section can result in incorrect billing and potential denials.
Some submitters neglect to provide complete provider information. This includes the provider’s name, Texas provider identifier (TPI), and national provider identifier (NPI). Missing or incorrect details can complicate the processing of your request.
Additionally, failing to sign the form is a common oversight. Both the prescribing physician and the therapists must provide their signatures and dates. A missing signature can halt the entire process.
People often submit the entire packet, including instruction pages, instead of just the authorization form. Only the completed authorization form should be sent. Extraneous pages can confuse the processing staff and lead to delays.
Finally, many individuals do not contact the TMHP-CSHCN Services Program Contact Center for assistance. If you have questions or uncertainties while filling out the form, don’t hesitate to reach out. Getting help can prevent mistakes and ensure that your request is processed smoothly.
Here are ten common misconceptions about the Texas Medicaid TP 1 form, along with clarifications to help you better understand the requirements.
Filling out the Texas Medicaid TP 1 form correctly is essential for ensuring that your request for outpatient therapy services is processed smoothly. Here are some key takeaways to keep in mind:
By following these guidelines, you can help ensure that your authorization request is processed efficiently and accurately.
Completing the Texas Medicaid TP 1 form is an essential step for accessing outpatient therapy services. To ensure that your request is processed efficiently, it is crucial to provide accurate and complete information. Following the steps outlined below will help you fill out the form correctly.