TX HHS Form 5204. Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Request

The TX HHS Form 5204, Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Request, is a crucial document for healthcare professionals to complete before performing office-based procedures in an ambulatory surgical center. This form helps solve the problem of ensuring that the necessary pre-authorization is obtained from Texas Health and Human Services (HHS) Breast and Cervical Cancer Services (BCCS) prior to commencing treatment.

The form requires essential information, including contractor details, client information, medical history, and procedure requests. Healthcare professionals must provide a detailed list of requested procedures, including the corresponding CPT codes from the BCCS Billing Guideline. It is essential to include both the physician and facility fee for each procedure, as any request without a facility fee listed will be denied.

To complete this form, healthcare professionals typically fill out the required information and email it along with supporting documentation to [email protected]. Key points to note include:

• The form is used for pre-authorization requests for office-based procedures performed in an ambulatory surgical center.
• A detailed list of requested procedures, including CPT codes and facility fees, must be provided.
• Any request without a facility fee listed will be denied.