The Texas Medicaid TP 1 form is a crucial document used for requesting authorization for initial outpatient therapy under the CSHCN Services Program. This form must be completed accurately and submitted in its most recent version to ensure that therapy services can be authorized without delay. Proper submission is essential, as incomplete requests may lead to claim denials, impacting the care that clients receive.
The Texas Medicaid TP 1 form, officially known as the CSHCN Services Program Authorization Request for Initial Outpatient Therapy, is a critical document for clients seeking outpatient therapy services. This form is essential for ensuring that requests for physical therapy, occupational therapy, and speech-language pathology services are processed efficiently. To avoid delays or denials, it is vital to submit the most current version of the form, which can be accessed on the TMHP website. Each section of the form must be completed thoroughly; incomplete submissions will lead to denial of authorization requests. The form requires detailed client information, including the client’s name, ID number, date of birth, and diagnosis. Additionally, it necessitates an evaluation summary, which must include the date of evaluation and the type of evaluation conducted. Service requests must specify procedure codes, modifiers, and the requested dates of service, which cannot exceed six months. The signatures of the prescribing physician and relevant therapists are also required to validate the request. For assistance, individuals can contact the TMHP-CSHCN Services Program Contact Center during business hours. Proper submission of the TP 1 form is crucial, as it directly impacts the approval of therapy services for clients enrolled in the CSHCN Services Program.
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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