Texas Medicaid uses TMHP form F00144 to prior authorize home oxygen therapy devices and supplies. A physician or allowed practitioner meets it when ordering oxygen, because Section B must be completed by the prescriber with the qualifying arterial blood gas or oxygen saturation results. The DME provider submits the request to TMHP for initial approval and renewals.
The rendering DME provider may complete Section A and signs a statement that the supplied items match the prescriber's order. The physician or allowed practitioner must complete and sign Section B, the oxygen therapy request and medical necessity documentation.
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Prior Authorization Request for Oxygen Therapy Devices and Supplies
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Section B must be completed and signed by the physician or allowed practitioner, including HCPCS codes, diagnosis, test results, flow rate and hours per day. The DME provider's representative signs Section A, certifying that the items are consistent with the prescriber's determination of medical necessity and safe for home use.
The form has a field for cluster headaches asking for the date of the neurological examination on initial requests. It also asks for documentation of failed medication therapy on initial requests, and whether oxygen is needed in the home and for travel outside the home.