The Texas Medicaid TP 1 form, officially known as the CSHCN Services Program Authorization Request for Initial Outpatient Therapy, is essential for requesting therapy services. It is crucial to submit the most recent version of this form to ensure your request is processed smoothly. To get started, fill out the form by clicking the button below.
The Texas Medicaid TP1 form, formally known as the CSHCN Services Program Authorization Request for Initial Outpatient Therapy, serves as a crucial document for obtaining authorization for therapy services under the Children with Special Health Care Needs (CSHCN) Services Program. This form must be filled out completely, as any omissions can lead to claim denials, thereby delaying necessary care for clients. It is essential to use the most current version of the TP1 form, which can be accessed through the Texas Medicaid Healthcare Partnership (TMHP) website. The form requires detailed client information, including the client’s name, ID number, date of birth, and address, as well as specific diagnosis codes relevant to their condition. Additionally, evaluators must provide a summary of the initial assessment, attaching a copy of the evaluation to the form. The service request section necessitates the inclusion of procedure codes, modifiers, and a clear outline of the requested therapy dates and frequency. Signatures from the prescribing physician and relevant therapists are also mandatory to validate the request. For providers, accurate information regarding their identifiers and contact details must be supplied, ensuring that all necessary components are in place for a successful authorization process. For assistance, individuals can reach out to the TMHP-CSHCN Services Program Contact Center during business hours.
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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Filling out the Texas Medicaid TP 1 form is an important step in securing authorization for outpatient therapy services. To ensure that your request is processed smoothly, follow these detailed steps. Remember to provide accurate information, as any mistakes or omissions can lead to delays or denials.
After submitting the TP 1 form, you can expect to receive confirmation regarding your authorization request. If you have any questions or need assistance, don't hesitate to reach out to the TMHP-CSHCN Services Program Contact Center during business hours.
The Texas Medicaid TP 1 form is the Authorization Request for Initial Outpatient Therapy specifically for the CSHCN Services Program. This form is used to request authorization for outpatient therapy services such as physical therapy, occupational therapy, and speech-language pathology. It ensures that the necessary evaluations and documentation are in place for clients who require these services.
To complete the TP 1 form accurately, follow these steps:
Remember, incomplete forms will lead to denial of the authorization request.
You can submit the TP 1 form in several ways:
TMHP-CSHCN Services Program Authorization Department 12357-B Riata Trace Parkway Ste #100 MC-A11 Austin, TX 78727
Make sure to submit only the authorization form and not the instruction pages.
If you need help while completing the TP 1 form, you can contact the TMHP-CSHCN Services Program Contact Center. They are available Monday through Friday from 7 a.m. to 7 p.m. Central Time. You can reach them at:
They will provide guidance and support to ensure your form is completed correctly.
Submitting an outdated form: Always ensure that you are using the most recent version of the TP1 form. Submitting an outdated form can lead to delays or denials of your request.
Leaving sections incomplete: It is crucial to fill out every section of the form. Incomplete forms will result in automatic denials, so double-check all entries before submission.
Failing to attach necessary documents: The initial evaluation must be attached to the form. Omitting this document can hinder the authorization process.
Not following submission guidelines: Submit only the authorization form itself. Do not include instruction pages, as this can confuse the processing team and delay your request.
The Texas Medicaid TP 1 form is a crucial document for obtaining authorization for outpatient therapy services under the CSHCN Services Program. However, several other forms and documents are often required to support the authorization request. Understanding these documents can streamline the process and help ensure a successful outcome. Below is a list of commonly used forms alongside the TP 1 form.
Being prepared with these forms can significantly enhance the efficiency of the authorization process for therapy services. It is essential to ensure that all required documents are completed accurately and submitted in a timely manner to avoid delays in care. For assistance, contacting the CSHCN Services Program Contact Center is recommended.
The Texas Medicaid TP 1 form shares similarities with the Prior Authorization Request form, often used in various healthcare settings. Both documents require detailed patient information, including names, dates of birth, and diagnosis codes. Each form necessitates signatures from healthcare providers, ensuring that the request is validated by a licensed professional. Furthermore, like the TP 1 form, the Prior Authorization Request form must be submitted in its entirety, as incomplete submissions can lead to denial of services. The process for submitting these forms, whether by mail or fax, is also similar, emphasizing the importance of following instructions carefully to avoid delays in service approval.
Another document that resembles the Texas Medicaid TP 1 form is the Therapy Evaluation Report. This report typically includes a comprehensive assessment of the patient's condition and outlines the recommended treatment plan. Both documents require an evaluation date and must include a summary of findings. Additionally, they both necessitate the involvement of qualified healthcare professionals, who must provide their signatures to confirm the accuracy of the information. The Therapy Evaluation Report often serves as a supporting document for the TP 1 form, further detailing the need for outpatient therapy services.
The Request for Medical Services form is another document that parallels the TP 1 form in structure and purpose. This form is used to obtain approval for various medical services, similar to how the TP 1 form is utilized for outpatient therapy. Both forms require specific information about the patient, including their identification details and diagnosis. In addition, they both mandate that healthcare providers sign and date the forms, confirming their endorsement of the requested services. The submission guidelines for the Request for Medical Services form mirror those of the TP 1, highlighting the necessity of complete and accurate documentation to prevent service denial.
Lastly, the Durable Medical Equipment (DME) Authorization Request form shares key characteristics with the Texas Medicaid TP 1 form. Both documents are designed to secure prior approval for services or equipment needed by patients. They require similar client information, including the patient’s name, date of birth, and diagnosis. Each form also emphasizes the importance of including signatures from healthcare providers, which validate the requests. The DME Authorization Request form and the TP 1 form both follow strict submission protocols, ensuring that all necessary documentation is provided to facilitate timely approval for the requested services.
When filling out the Texas Medicaid TP 1 form, attention to detail is crucial. Here are five essential do's and don'ts to ensure a successful submission.
When it comes to the Texas Medicaid TP 1 form, several misconceptions can lead to confusion and errors. Understanding the truth behind these myths is essential for a smooth application process. Here are seven common misconceptions:
By addressing these misconceptions, individuals can better navigate the Texas Medicaid TP 1 form process, ensuring that their requests are handled efficiently and correctly.
When filling out the Texas Medicaid TP 1 form, it's crucial to follow specific guidelines to ensure a smooth process. Here are key takeaways:
Following these guidelines will help in the successful submission and processing of the TP1 form.