TMHP's Special Medical Prior Authorization (SMPA) department reviews Texas Medicaid requests for certain procedures and services, and form F00087 is its request. A physician meets it when a planned transplant, surgery, EKG or other listed procedure needs approval. The physician supplies the diagnoses and a statement of medical necessity based on the relevant section of the Texas Medicaid Provider Procedures Manual.
The requesting physician or allowed practitioner completes Sections A to C, including the CPT codes, diagnoses, statement of medical necessity, NPI and signature. Section D is completed for the rendering provider or facility when it differs from the requester.
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Special Medical Prior Authorization (SMPA) Request Form
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The form directs the requester to the appropriate section of the Texas Medicaid Provider Procedures Manual for the specific prior authorization requirements of the procedure. Section C holds the diagnoses and statement, signed by the requesting physician or allowed practitioner, and further documentation may be attached.
Section B offers transplant, surgery, EKG and other, with expected dates of service and the CPT code and description for each procedure. Other TMHP prior authorization forms exist for radiology, obstetric ultrasound and reduction mammaplasty, so those go on their own forms rather than F00087.