CCP Prior Authorization Request Form - PDF Details

The CCP Prior Authorization Request Form is a required document for healthcare providers in the Texas Medicaid Community Care Program (CCP) who need prior approval before delivering specific services. This form covers Durable Medical Equipment (DME), medical supplies, private duty nursing (PDN), post-acute and extended care employment coordination (PPECC), inpatient rehabilitation, and other services that require advance authorization from the Texas Health and Human Services Commission (HHSC).

Who Must Complete This Form

Suppliers, vendors, home health agencies, and qualified rehabilitation professionals (QRPs) complete this CCP Prior Authorization Request Form when requesting approval on behalf of a Medicaid-enrolled client. Healthcare providers should assign a dedicated billing or authorization coordinator to manage these submissions, since incomplete forms are returned without processing and delays can affect patient care.

Services Covered by the Authorization Form

The form applies to several categories of service under the Texas Medicaid CCP program:

Sections Covered in the Form

The CCP Prior Authorization Request Form is organized into labeled sections. Section A covers client information including name, Medicaid number, and date of birth. Section B captures the rendering provider or supplier details including NPI and Taxonomy code. Section C identifies the request type (new, recertification, or revision) and relevant dates. Section D documents the diagnosis and medical necessity narrative with ICD-10 codes. Section E lists HCPCS codes, modifiers, quantities, frequencies, and retail prices for each requested item. Section F requires the primary practitioner's original signature certifying the medical appropriateness of the request.

Submission Requirements

Once all sections of the CCP Prior Authorization Request Form are complete, fax the document to 1-512-514-4212. Keep a copy of the fax confirmation for your records. The HHSC reviews each prior authorization request based on medical necessity criteria and current program guidelines. Requests with missing information are returned without a decision, which restarts the waiting period for the provider and the client.

QuestionAnswer
Form NameCcp Prior Authorization Request Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesPCN, HCPCS, certifications, CCP

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The CCP Prior Authorization Request Form can be completed effortlessly using FormsPal's online PDF editor. We continuously update our tool to make form completion faster and more accurate. Follow these steps to fill out and download your form:

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1. Begin with the client and provider details in Sections A and B. Enter the client name (last, first, MI), Medicaid number, date of birth, and supplier or vendor information including name, street address, city, and NPI number.

CCP Prior Authorization Request Form part 1 - client and provider information fields

2. Complete the remaining fields in Section B including DME and City entries. Double-check these fields carefully since they are among the most important for accurate routing of your CCP Prior Authorization Request.

CCP Prior Authorization Form section 2 - rendering provider details

3. In Section C, indicate whether this is a new request, a recertification, or a revision. Enter the requested start and end dates. For revisions, include the reason and note that the end date cannot extend beyond the original authorization period.

CCP Prior Authorization Form section 3 - request type and dates

4. Section E requires HCPCS codes, modifiers, brief descriptions, quantities, frequencies, and retail prices for each requested item or service. Mark essential or critical fields accurately. Include the page number at the bottom of any continuation page.

CCP Prior Authorization Request Form part 4 - HCPCS code fields

5. Section F covers the primary practitioner certifications. For DME requests, confirm the client meets the age and medical necessity requirements. For private duty nursing, include the age attestation if the client is under the specified age. The practitioner must sign and date this section with an original signature.

CCP Prior Authorization Form section 5 - practitioner certifications and signature

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Related Prior Authorization Forms

If you manage multiple Texas Medicaid prior authorization requests, these related forms are also available on FormsPal:

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