Contents
Form Example
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
•This form may be submitted by mail to the following address:
Austin, TX 78727
•This form may be submitted by fax to
•Submit only the authorization form. Do not submit instruction pages.
•Refer to: Chapter 30, “Physical Medicine and Rehabilitation” and Chapter 36,
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Client Information |
Field Description |
Guidelines |
First name |
Enter the client’s first name as indicated on the CSHCN Services |
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Program eligibility form |
Last name |
Enter the client’s last name as indicated on the CSHCN Services |
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Program eligibility form |
CSHCN Services Program |
Enter the client’s ID number as indicated on the CSHCN Services |
number |
Program eligibility form |
Date of birth |
Enter the client’s date of birth as indicated on the CSHCN Services |
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Program eligibility form |
Address/City/ZIP |
Enter the client’s address, city, and ZIP |
Diagnosis |
Enter the diagnosis code relevant to the client’s condition. |
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Evaluation Summary |
Field Description |
Guidelines |
Date of evaluation |
Enter the date of evaluation. |
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Note: A copy of the initial evaluation must be attached. |
Type of evaluation |
Check the appropriate type of evaluation |
Comments |
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Service Request |
Field Description |
Guidelines |
Service request |
Indicate procedure code(s), modifier, the dates of service, and the |
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frequency per week or month. Dates of service cannot exceed six |
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months. If possible, end requested date(s) of service on the last day |
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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 |
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signature |
OT name, signature, and date |
Indicate the occupational therapist’s name, signature, and date of |
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signature |
F00009 |
Page 1 of 3 |
Effective Date_03172014/Revised Date_05202014 |
Field Description |
Guidelines |
SLP name, signature, and date |
Indicate the speech language pathologist’s name, signature, and |
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date of signature |
Provider Information and Required Signature |
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Field Description |
Guidelines |
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 |
Address/City/ZIP |
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
F00009 |
Page 2 of 3 |
Effective Date_03172014/Revised Date_05202014 |
CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1)
Please print or type requested information below.
Client Information
First name: |
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Last name: |
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CSHCN Services Program number: 9- |
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Date of birth: |
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Address/City/ZIP: |
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Diagnoses: |
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Evaluation Summary: |
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Date of evaluation: |
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(A copy of the initial evaluation must be attached.) |
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Type of evaluation: □ Physical Therapy (PT) |
□ Occupational Therapy (OT) □ Speech Language Pathology (SLP) |
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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 |
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Physician name: |
Physician signature: |
Date: |
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PT name: |
PT signature: |
Date: |
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OT name: |
OT signature: |
Date: |
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SLP name: |
SLP signature: |
Date: |
Provider Information and Required Signature:
Provider name:
CSHCN TPI: |
NPI: |
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Taxonomy code: |
Benefit code: CSN |
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Provider contact name: |
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Telephone number: |
Fax number: |
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Address/City/ZIP: |
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Signature of provider: |
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Date: |
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F00009 |
Page 3 of 3 |
Effective Date_03172014/Revised Date_05202014 |
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Common mistakes
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Using an outdated form: Many individuals fail to check if they are using the most recent version of the TP1 form. It is crucial to download the latest version from the TMHP website to ensure compliance with current requirements.
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Leaving sections incomplete: Incomplete forms lead to automatic denials. Each section of the TP1 form must be filled out completely. This includes client information, evaluation summary, and service request details.
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Not attaching necessary documents: Some applicants forget to include a copy of the initial evaluation. This document is essential for processing the request and must accompany the TP1 form.
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Incorrectly entering diagnosis codes: Entering the wrong diagnosis code can result in a denial of services. It is important to ensure that the diagnosis code matches the client’s condition as indicated on the eligibility form.
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Failing to use proper modifiers: When requesting authorization for physical therapy and occupational therapy services, the appropriate modifiers (GP for PT and GO for OT) must be used. Neglecting to include these can lead to processing delays or denials.
Key takeaways
When filling out the Texas Medicaid TP 1 form, there are several important points to consider to ensure a smooth submission process. Below are key takeaways that can guide you through this process.
- Use the Latest Version: Always ensure that you are using the most recent version of the TP 1 form, which can be found on the TMHP website at www.tmhp.com.
- Complete All Sections: It is crucial to fill out every section of the form. Incomplete forms will lead to denial of the authorization request.
- Print or Type Information: All information should be printed or typed clearly to avoid any misunderstandings.
- Contact for Assistance: If you have questions, reach out to the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000, option 2, during business hours.
- Submission Methods: The form can be submitted via mail or fax. For mail, send it to the TMHP-CSHCN Services Program Authorization Department in Austin, TX. For fax, use the number 1-512-514-4222.
- Do Not Include Instruction Pages: Only submit the completed authorization form; do not send any instruction pages.
- Attach Evaluation Copy: Make sure to attach a copy of the initial evaluation to the form, as this is a requirement.
- Use Correct Modifiers: When requesting authorization for physical therapy (PT) and occupational therapy (OT), use the GP and GO modifiers, respectively. For speech-language pathology (SLP) services, use the GN modifier.
- Check Dates of Service: The dates of service requested should not exceed six months. If possible, aim to conclude the requested dates on the last day of a month.
Steps to Using Texas Medicaid Tp 1
Completing the Texas Medicaid TP 1 form requires careful attention to detail. Ensure that all sections are filled out accurately to avoid any delays or denials in processing. After submitting the form, the next steps involve waiting for authorization and any potential follow-up communication from the relevant authorities.
- Obtain the most recent version of the TP 1 form from the TMHP website at www.tmhp.com.
- Print or type the required information clearly in all sections of the form.
- Fill out the Client Information section:
- Enter the client’s first name.
- Enter the client’s last name.
- Input the client’s CSHCN Services Program ID number.
- Provide the client’s date of birth.
- Fill in the client’s address, city, and ZIP code.
- Enter the relevant diagnosis code.
- Complete the Evaluation Summary section:
- Input the date of evaluation.
- Attach a copy of the initial evaluation.
- Select the type of evaluation (PT, OT, or SLP).
- Provide any additional comments if necessary.
- Fill out the Service Request section:
- Indicate the procedure code(s) and modifier.
- Specify the dates of service and frequency per week or month.
- Ensure that dates of service do not exceed six months.
- If possible, end requested dates on the last day of a month.
- Complete the signatures for the physician, physical therapist, occupational therapist, and speech language pathologist, including their names, signatures, and dates.
- Fill out the Provider Information section:
- Enter the provider’s name.
- Provide the provider’s Texas provider identifier (TPI) and national provider identifier (NPI).
- Input the provider’s taxonomy code and benefit code.
- Enter the provider contact name, telephone number, and fax number.
- Fill in the provider’s address, city, and ZIP code.
- Obtain the provider’s signature and the date of signing.
- Review the form for completeness and accuracy.
- Submit the completed form by mail or fax:
- Mail to: TMHP-CSHCN Services Program Authorization Department, 12357-B Riata Trace Parkway Ste #100 MC-A11, Austin, TX 78727.
- Fax to: 1-512-514-4222.
- Do not submit instruction pages along with the form.