[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283950-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283950-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","psychiatric-inpatient-extended-stay-request-form-prior-authorization","Psychiatric Inpatient Extended Stay Request Form - Prior Authorization","","Psychiatric Inpatient Extended Stay Request Form for submitting a prior authorization request to support extended inpatient psychiatric care under Texas Medicaid. The form explains how to submit through TMHP’s PA on the Portal for faster receipt and decisions versus scanned fax submissions. It includes a Prior Authorization Request Submitter Certification Statement, client and facility information, clinical symptom and diagnostic sections, drug/alcohol usage, current and past psychiatric treatment, discharge criteria, and treatment/contact plan fields, with essential fields marked as required.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/psychiatric-inpatient-extended-stay-request-form-prior-authorization/283950/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/psychiatric-inpatient-extended-stay-request-form-prior-authorization/283950.png","ImageObject",442,249,{"name":42,"@type":43},"วิน","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How should the prior authorization request be submitted for faster decisions?","Question",{"text":63,"@type":64},"Submit prior authorization using TMHP’s PA on the Portal. Documents are immediately received by the PA Department, which leads to quicker request decisions than fax submissions.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What happens if part of the form is incomplete?",{"text":68,"@type":64},"If any portion of the form is incomplete, the prior authorization request may be pended for additional information.",{"name":70,"@type":61,"acceptedAnswer":71},"Which fields are considered essential or critical?",{"text":72,"@type":64},"Fields marked with an asterisk are essential/critical. If these fields are not completed, the prior authorization request will be returned.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283950,1791035861,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},2336475104736,"https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222","Psychiatric Inpatient Extended Stay Request Form  \nSubmit your prior authorization using TMHP’s PA on the Portal and receive request decisions more quickly than faxed requests. With PA on the Portal, documents will be immediately received by the PA Department, resulting in a quicker decision. Fax requests must be scanned and data entered before the PA Department receives them, which can take up to 24 hours. To access PA on the Portal, go to www.tmhp.com and select“Prior Authorization” from the Topics drop-down menu. Then click the PA on the Portal button and enter your TMHP Portal Account user name and password. To submit by fax, send to 512-514-4211.  \nNote: If any portion of this form is incomplete, it may result in your prior authorization request being pended for additional information.  \n\n| Prior Authorization Request Submitter Certification Statement |\n| --- |\n| I certify and affirm that I am either the Provider, or have been specifically authorized by the Provider (hereinafter “Prior Authorization Request Submitter”) to submit this prior authorization request. The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are personally acquainted with the information supplied on the prior authorization form and any attachments or accompanying information and that it constitutes true, correct, complete and accurate information; does not contain any misrepresentations; and does not fail to include any information that might be deemed relevant or pertinent to the decision on which a prior authorization for payment would be made.\u003Cbr>The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the information supplied on the prior authorization form and any attachments or accompanying information was made by a person with knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the ordinary course of business of the Provider; is the original or an exact duplicate of the original; and is maintained in the individual patient’s medical record in accordance with the Texas Medicaid Provider Procedures Manual (TMPPM).\u003Cbr>The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that prior authorization is a condition of reimbursement and is not a guarantee of payment.\u003Cbr>The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior authorization will be from Federal and State funds, and that any false claims, statements or documents, concealment of a material fact, or omitting relevant or pertinent information may constitute fraud and may be prosecuted under applicable federal and/or State laws. The Provider and Prior Authorization Request Submitter understand and agree that failure to provide true and accurate information, omit information, or provide notice of changes to the information previously provided may result in termination of the provider’s Medicaid enrollment and/or personal exclusion from Texas Medicaid.\u003Cbr>The Provider and Prior Authorization Request Submitter certify, affirm and agree that by checking “We Agree” that they have read and understand the Prior Authorization Agreement requirements as stated in the relevant Texas Medicaid Provider Procedures Manual and they agree and consent to the Certification above and to the Texas Medicaid & Healthcare Partnership (TMHP) Terms and Conditions.\u003Cbr>We Agree |\n\nPsychiatric Inpatient Extended Stay Request Form  \nNote: Fields marked with an asterisk below indicate an essential/critical field. If these fields are not completed, your prior authorization request will be returned.  \n\n| A. Client Information |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Client Name*: |  |  |  |  |  |  |  |  |  |  |\n| Medicaid Number*: |  |  |  |  |  |  | Date ofBirth*: |  |  |  |\n| Age: | Sex: |  | Date of Admission: |  |  |  | Date","cbCain4Y53ZuNkM8","https://ap.wps.com/l/cbCain4Y53ZuNkM8","pdf",92309,"English","# Prior Authorization Submission Instructions\n## Portal vs Fax Requirements\n## Certification Statement\n# Form Sections\n## Client Information\n## Rendering Facility Information\n## Primary Symptoms and Current Status\n## Clinical/Diagnostic Information (Past 72 Hours)\n## Drug/Alcohol Usage\n## Current Psychiatric Medication\n## Past Psychiatric Treatment\n## Discharge Criteria\n## Treatment, Contacts, Plans","[{\"question\":\"How should the prior authorization request be submitted for faster decisions?\",\"answer\":\"Submit prior authorization using TMHP’s PA on the Portal. Documents are immediately received by the PA Department, which leads to quicker request decisions than fax submissions.\"},{\"question\":\"What happens if part of the form is incomplete?\",\"answer\":\"If any portion of the form is incomplete, the prior authorization request may be pended for additional information.\"},{\"question\":\"Which fields are considered essential or critical?\",\"answer\":\"Fields marked with an asterisk are essential/critical. If these fields are not completed, the prior authorization request will be returned.\"}]","Psychiatric Inpatient Extended Stay Request Form - Prior Authorization | PDF",1789623394]