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Content Overview

The Texas Medicaid TP 1 form, officially known as the CSHCN Services Program Authorization Request for Initial Outpatient Therapy, is a crucial document for families seeking therapy services for children with special health care needs. This form is designed to facilitate the authorization process for initial outpatient therapy, ensuring that all necessary information is captured accurately. It is essential to use the most recent version of the form, which can be found on the TMHP website. To avoid delays, all sections of the form must be completed fully, as any missing information can lead to claim denials. The form requires details such as the client’s name, date of birth, and diagnosis, along with a summary of the evaluation conducted. Furthermore, it includes sections for service requests, where specific procedure codes, modifiers, and the frequency of therapy sessions need to be indicated. The form also mandates signatures from the prescribing physician and therapists involved, ensuring that all parties are in agreement regarding the proposed services. For added convenience, the TP 1 form can be submitted via mail or fax, but it is important to submit only the authorization form and not any instruction pages. Assistance is readily available through the TMHP-CSHCN Services Program Contact Center, where representatives can guide families through the process and answer any questions they may have.

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F00009 Page 1 of 3 Effective Date_03172014/Revised Date_05202014
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
Program eligibility form
CSHCN Services Program
number
Enter the client’s ID number as indicated on the CSHCN Services
Program eligibility form
Date of birth Enter the client’s date of birth as indicated on the CSHCN Services
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.
Evaluation Summary
Field Description Guidelines
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
Field Description Guidelines
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,
and date
Indicate the prescribing physician’s name, signature, and date of
signature
PT name, signature, and date Indicate the physical therapist’s name, signature, and date of
signature
OT name, signature, and date Indicate the occupational therapist’s name, signature, and date of
signature
F00009 Page 2 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
date of signature
Provider Information and Required Signature
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 3 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: 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: Date:
OT name: OT signature: Date:
SLP name: SLP signature: Date:
Provider Information and Required Signature:
Provider name:
CSHCN TPI: NPI:
Taxonomy code:
Benefit code: CSN
Provider contact name:
Telephone number: Fax number:
Address/City/ZIP:
Signature of provider: Date:
➤ PDF File

Form Specifications

Fact Name Description
Form Purpose The TP1 form is used to request authorization for initial outpatient therapy services under the CSHCN Services Program.
Submission Guidelines Ensure that the most recent version of the TP1 form is submitted to avoid delays or denials.
Contact Information For assistance, contact the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000, Monday to Friday, from 7 a.m. to 7 p.m. CT.
Submission Methods The form can be submitted by mail or fax. The mailing address is TMHP-CSHCN Services Program Authorization Department, 12357-B Riata Trace Parkway Ste #100 MC-A11, Austin, TX 78727. Fax submissions go to 1-512-514-4222.
Completeness Requirement All sections of the TP1 form must be completed. Incomplete forms will lead to claim denials.
Diagnosis Entry Enter the diagnosis code relevant to the client’s condition as indicated on the eligibility form.
Evaluation Attachment A copy of the initial evaluation must be attached to the form when submitted.
Modifier Usage When requesting authorization for physical therapy (PT) and occupational therapy (OT), use the GP and GO modifiers, respectively.
Governing Laws The TP1 form is governed by Chapter 30, “Physical Medicine and Rehabilitation,” and Chapter 36, “Speech-Language Pathology (SLP) Services,” of Texas Medicaid regulations.
Client Information Ensure accurate entry of the client's first name, last name, CSHCN Services Program number, date of birth, and address to prevent processing issues.

Texas Medicaid Tp 1: Usage Guidelines

Completing the Texas Medicaid TP 1 form is essential for obtaining authorization for outpatient therapy services. It is important to ensure that every section is filled out accurately to avoid any delays or denials in the authorization process. Below are the steps to properly complete the form.

  1. Obtain the most recent version of the TP 1 form from the TMHP website at www.tmhp.com.
  2. Print or type all required information clearly in the designated sections.
  3. Fill out the Client Information section with the client's first name, last name, CSHCN Services Program number, date of birth, address, city, ZIP code, and diagnosis code.
  4. Complete the Evaluation Summary section by entering the date of evaluation and checking the appropriate type of evaluation. Remember to attach a copy of the initial evaluation.
  5. In the Service Request section, indicate the procedure code(s), modifier(s), dates of service, and frequency of service per week or month. Ensure that the dates of service do not exceed six months and, if possible, end on the last day of a month.
  6. Provide the names, signatures, and dates for the prescribing physician, physical therapist, occupational therapist, and speech language pathologist in their respective fields.
  7. Fill out the Provider Information section with the provider’s name, Texas provider identifier (TPI), national provider identifier (NPI), taxonomy code, benefit code, contact name, telephone number, fax number, and address.
  8. Ensure the provider signs in the designated area and includes the date of signing.
  9. Review the form for completeness and accuracy, ensuring no instruction pages are submitted.
  10. Submit the form by mailing it to the TMHP-CSHCN Services Program Authorization Department at the specified address or faxing it to the provided number.

Following these steps will help ensure that the TP 1 form is completed correctly and submitted for processing without unnecessary delays. If there are any questions during the process, assistance is available through the TMHP-CSHCN Services Program Contact Center.

Your Questions, Answered

What is the Texas Medicaid TP 1 form?

The Texas Medicaid TP 1 form, formally known as the CSHCN Services Program Authorization Request for Initial Outpatient Therapy, is a document required for obtaining authorization for specific outpatient therapy services. This includes physical therapy, occupational therapy, and speech-language pathology services. It is essential to complete this form accurately to ensure that the request for therapy is processed smoothly and without delays.

Where can I find the TP 1 form?

The most recent version of the TP 1 form can be accessed on the TMHP website at www.tmhp.com. It is crucial to use the latest version to avoid any complications with your submission. Always check for updates before filling out the form to ensure compliance with the current requirements.

What happens if I submit an incomplete TP 1 form?

Submitting an incomplete TP 1 form can lead to the denial of your authorization request. It is vital to complete all sections of the form thoroughly and accurately. Incomplete requests will not be processed, which could delay necessary therapy services for the client. To prevent this, double-check that every field is filled out before submission.

How do I submit the TP 1 form?

The TP 1 form can be submitted in several ways. You may mail it to the TMHP-CSHCN Services Program Authorization Department at the specified address in Austin, Texas. Alternatively, you can fax the completed form to 1-512-514-4222. It is important to note that only the authorization form should be submitted; do not include any instruction pages with your submission.

What information is required on the TP 1 form?

The TP 1 form requires various pieces of information, including the client's name, date of birth, address, and diagnosis code. Additionally, details about the evaluation, such as the date and type of evaluation, must be included. You will also need to provide specific service request information, including procedure codes, modifiers, and the frequency of therapy sessions. Signatures from the prescribing physician and relevant therapists are also necessary.

Who can I contact for assistance with the TP 1 form?

If you need help with the TP 1 form, you can reach out to 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 call them at either 1-800-568-2413 or 1-512-514-3000, option 2. They can provide guidance and answer any questions you may have about the form and the submission process.

Common mistakes

  1. Using an outdated version of the form. Always ensure that the most recent version of the TP1 form is submitted. The latest form can be found on the TMHP website.

  2. Leaving sections incomplete. All sections of the form must be filled out. Incomplete requests will lead to automatic denial of the claim.

  3. Handwriting that is unclear. It is crucial to print or type all information clearly. Illegible handwriting can cause confusion and delays.

  4. Not attaching required documents. A copy of the initial evaluation must accompany the form. Failure to include this will result in denial.

  5. Incorrect diagnosis code. Ensure the diagnosis code accurately reflects the client's condition. An incorrect code can lead to processing issues.

  6. Not adhering to service request guidelines. Indicate the correct procedure codes, modifiers, and service dates. Dates of service should not exceed six months.

  7. Missing signatures. The form requires signatures from the prescribing physician, physical therapist, occupational therapist, and speech-language pathologist. Missing signatures will delay the process.

  8. Failure to use correct modifiers. PT and OT services require specific modifiers (GP for PT and GO for OT). Ensure these are included to avoid denials.

  9. Not verifying provider information. Double-check that the provider's name, Texas provider identifier (TPI), and national provider identifier (NPI) are accurate. Errors can lead to complications in processing.

Documents used along the form

The Texas Medicaid TP 1 form is an essential document for requesting authorization for outpatient therapy services. Along with this form, several other documents are frequently required to ensure a complete and accurate submission. Below is a list of these documents, each accompanied by a brief description.

  • Initial Evaluation Report: This document provides a detailed assessment of the client's condition and must accompany the TP 1 form. It outlines the findings and justifications for the requested therapy services.
  • Client Eligibility Form: This form verifies the client’s eligibility for the CSHCN Services Program. It includes essential information such as the client’s ID number and demographic details.
  • Physician's Order: A signed order from the prescribing physician is necessary. It confirms the need for therapy services and includes the physician's details and signature.
  • Service Provider's Credentials: Documentation of the service provider’s qualifications, including their Texas provider identifier (TPI) and national provider identifier (NPI), is required to validate their ability to provide the requested services.
  • Insurance Information: A copy of the client’s insurance card may be needed to confirm coverage and benefits. This helps in determining the financial aspects of the requested services.
  • Authorization Request Cover Letter: This letter can accompany the TP 1 form to summarize the request. It should include the client’s information and a brief explanation of the therapy services being requested.

Ensuring that all these documents are completed and submitted correctly will help facilitate a smoother authorization process for therapy services under the Texas Medicaid program.

Similar forms

  • Medicaid Application Form: Similar to the TP1 form, this document collects client information and eligibility details for Medicaid services.
  • Prior Authorization Request Form: Like the TP1 form, it requires specific information about the requested services and client diagnosis to obtain approval.
  • Physical Therapy Evaluation Form: This form documents the evaluation process and findings, similar to the evaluation summary section of the TP1 form.
  • Occupational Therapy Evaluation Form: It serves a similar purpose to the TP1 form by capturing essential details regarding the client's occupational therapy needs.
  • Speech-Language Pathology Evaluation Form: This document is akin to the TP1 form, focusing on the evaluation and service request for speech therapy.
  • Client Information Update Form: This form updates client details, similar to how the TP1 form collects and verifies client information.
  • Authorization for Release of Information Form: Like the TP1 form, this document ensures that necessary information is shared for service authorization.
  • Medicaid Provider Enrollment Form: Similar to the TP1 form, it collects essential information about providers to ensure they are eligible to offer services.
  • Service Plan Authorization Form: This document outlines the services needed, similar to the service request section of the TP1 form.
  • Claim Submission Form: Like the TP1 form, this document is used to submit requests for payment for services rendered, ensuring all required information is included.

Dos and Don'ts

When filling out the Texas Medicaid TP 1 form, attention to detail is crucial. The following list outlines important dos and don’ts to ensure your submission is successful.

  • Do use the most recent version of the TP 1 form, available on the TMHP website.
  • Do complete all sections of the form to avoid denial of your request.
  • Do print or type all information clearly for legibility.
  • Do attach a copy of the initial evaluation as required.
  • Do indicate the correct procedure codes and modifiers for the services requested.
  • Don't submit instruction pages along with the authorization form.
  • Don't leave any sections blank, as incomplete forms will be denied.
  • Don't exceed six months for the requested dates of service.
  • Don't forget to sign the form where required by all relevant parties.
  • Don't hesitate to contact the TMHP-CSHCN Services Program for assistance if needed.

By following these guidelines, you can help ensure that your authorization request is processed smoothly and efficiently.

Misconceptions

Misconceptions about the Texas Medicaid TP 1 form can lead to delays and complications in obtaining necessary services. Here are eight common misunderstandings:

  • The TP 1 form is optional. Many believe that submitting the TP 1 form is not necessary. In reality, this form is required for authorization of outpatient therapy services.
  • Any version of the form can be used. Some think that older versions of the TP 1 form are acceptable. Only the most recent version, available on the TMHP website, should be submitted.
  • Incomplete forms will still be processed. There is a misconception that incomplete forms will be accepted. However, any missing information will lead to claim denial.
  • Faxing the form is not allowed. Some individuals believe that the TP 1 form can only be mailed. In fact, it can also be submitted via fax to the designated number.
  • Only the client needs to sign the form. It is often assumed that only the client’s signature is necessary. However, signatures from all relevant healthcare providers are required.
  • Diagnosis codes are not important. Some may think that diagnosis codes can be skipped. This is incorrect; accurate diagnosis codes are essential for proper processing.
  • Dates of service can exceed six months. There is a belief that service dates can be flexible. In truth, dates cannot exceed six months, and it is recommended to end on the last day of a month.
  • Contacting TMHP is unnecessary. Many feel they can fill out the form without assistance. However, contacting the TMHP-CSHCN Services Program for help can prevent errors and ensure correct submission.

Key takeaways

Filling out the Texas Medicaid TP1 form correctly is essential for ensuring that clients receive the necessary outpatient therapy services. Here are some key takeaways to keep in mind:

  • Use the Latest Version: Always ensure that you are using the most recent version of the TP1 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 submissions will lead to denial of the authorization request.
  • Print or Type: All information should be clearly printed or typed to avoid any misunderstandings or errors.
  • Contact for Assistance: If you have questions or need help, 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: You can submit the form by mail or fax. The mailing address is TMHP-CSHCN Services Program Authorization Department, 12357-B Riata Trace Parkway Ste #100 MC-A11, Austin, TX 78727, and the fax number is 1-512-514-4222.
  • Submit Only the Form: Make sure to submit only the authorization form itself. Do not include instruction pages.
  • Attach Evaluation Copy: A copy of the initial evaluation must be attached to the form. This is a requirement for processing the request.
  • Use Correct Modifiers: Remember to use the appropriate modifiers for therapy services. For physical therapy, use the GP modifier; for occupational therapy, use the GO modifier; and for speech-language pathology, use the GN modifier.
  • Check Service Dates: Ensure that the dates of service do not exceed six months and, if possible, end on the last day of a month.