CCP Prior Authorization Request Form - Fill Out and Download Your PDF

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:

• Durable Medical Equipment (DME) and related medical supplies
• Private duty nursing (PDN) and personal care assistance
• Post-acute and extended care employment coordination (PPECC)
• Inpatient rehabilitation services
• Other medically necessary services not covered without prior authorization

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.