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 seeking pre-authorization for office-based procedures performed in ambulatory surgical centers. This form helps solve the problem of obtaining prior approval from Breast and Cervical Cancer Services (BCCS) before initiating treatment.

To complete this form, users must provide essential information about the patient, including name, date of birth, medical history, and physical information. The form also requires details on recent screening and diagnostic procedures received through BCCS or prior to referral. Key sections include "History and Physical Information" and "Requested Procedures(s)" where users must list CPT codes from the BCCS Billing Guideline.

This form should be used when seeking pre-authorization for office-based procedures performed in ambulatory surgical centers, particularly for patients referred to BCCS for treatment. It is essential to include a facility fee code for each requested procedure, as any request without this information will be denied. The completed form should be emailed along with supporting documentation to [email protected].