Home Telemonitoring Services Prior Authorization Request Form Page 2
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2Home Telemonitoring Services Prior Authorization Request
Texas Medicaid
Fax the completed form to the Texas Medicaid Special Medical Prior Authorization department at 1-512-514-4213.
All sections of the form must be completed unless otherwise stated.
Section A: Client information (completed by home health agency or outpatient hospital)
Name:
First:
Last:
Medicaid number:
Date of birth:
Section B: Requested telemonitoring service information (completed by home health agency or
outpatient hospital)
Home telemonitoring qualifying diagnosis:
Diabetes
Hypertension
Requested dates of service From:
To:
Physician-ordered frequency of clinical data transmission:
Comments (optional):
Client Risk Factors (check all that apply):
Two or more hospitalizations in the prior 12-month period
Frequent or recurrent emergency department visits
Documented history of poor adherence to ordered medication regimens
Documented history of falls in the prior six-month period
Limited or absent informal support systems
Living alone or being home alone for extended periods of time
Documented history of care access challenges
Section C: Physician information (may be completed by home health agency, outpatient hospital,
or physician ordering home telemonitoring)
Physician’s name:
TPI or NPI:
Physician signature is required unless one of the following from the physician is attached to the request:
•
Signed and dated prescription
•
Dated written order
•
Dated documented verbal order (may be on a plan of care or treatment plan)
Physician’s signature:
Date signed:
Section D: Telemonitoring provider information (completed by home health agency or outpatient
hospital)
Provider printed name:
Contact person:
Address/City/ZIP:
Telephone number:
Fax number:
TPI:
NPI:
Provider’s Signature:
Date signed:
F00032
Page 2 of 2
Revised Date: 02/01/2016 | Effective Date: 04/01/2016
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