How to Complete the Texas Title XIX Home Health DME Order Form

The Texas Title XIX Home Health DME order form (Form F00030) is how a prescribing physician asks Texas Medicaid to cover durable medical equipment and supplies for a patient receiving home health services. You complete Section A with the items and their HCPCS codes, Section B with the diagnosis and medical necessity narrative, collect signatures from both the physician and a DME provider representative, and fax the finished form to the Texas Medicaid & Healthcare Partnership (TMHP) at (512) 514-4209 for prior authorization. A complete request can clear in as few as three business days.¹ The blank form is on the TMHP forms page at tmhp.com.²

What to Gather First

Pulling the right information together before you start writing prevents the back-and-forth that stalls authorization. You need:

The patient’s nine-digit Medicaid number, which appears on the front of the Medicaid card.³
The ICD-10 code for each diagnosis that supports an item on the order. Vague or mismatched codes are a common reason for delays.
The HCPCS code for every item. If the item has a maximum fee in the Texas Medicaid Fee Schedule, no price entry is needed. If it requires manual pricing, you also need the manufacturer’s suggested retail price.⁴
The prescribing physician’s ten-digit National Provider Identifier and license number.⁵
Clinical documentation of the patient’s functional limitations and relevant measurements — oxygen saturation, wound stage and dimensions, range of motion, height and weight. These feed directly into the medical necessity narrative.

Keep the governing standard in mind as you work. Texas Administrative Code §354.1039 requires that the equipment be medically necessary, safe for home use, documented in the recipient’s plan of care or on the order form, and prescribed by a physician or allowed practitioner.⁶ Items that serve only comfort or convenience — air conditioners, bathtub seats, bed elevators — are routinely denied.

The Six-Month Physician Visit Rule

Before signing the form, the prescribing physician or allowed practitioner must have seen the patient within the past six months. The visit can be in person or through a Medicaid-approved telemedicine appointment. Without a documented evaluation inside that window, the form is invalid and TMHP will not process it.⁷

For certain devices, such as continuous glucose monitors, the visit specifically must evaluate the patient’s condition and confirm that the clinical criteria for that device are met. The notes from that visit become the raw material for the Section B justification, so the evaluation should document the specific functional limitations that make the equipment necessary.

Filling Out Section A

Section A lists what the patient needs. Either the rendering provider or the prescribing physician can complete it, but you must check the box indicating who did.⁴ For each item, enter a sequential item number, the HCPCS code, a plain-language description (for example, “manual wheelchair” or “nebulizer”), the quantity, and the price if the item requires manual pricing. The item numbers matter because Section B references them to link each piece of equipment back to its diagnosis.

Wheeled mobility systems and major modifications to them trigger extra fields. The supplier or a Qualified Rehabilitation Professional (QRP) must complete the QRP’s name, NPI, address, Tax ID, benefit code, and taxonomy. Requests for items that exceed standard quantity limits or involve custom equipment need additional documentation supporting medical necessity.

Filling Out Section B

Section B is the physician’s territory. Only the prescribing physician or allowed practitioner can fill it out, and for each item in Section A it must contain:

The corresponding item number from Section A.
The ICD-10 diagnosis code and a brief description of the condition.
A medical necessity narrative explaining why this patient needs this specific equipment. Avoid vague statements like “patient has mobility issues.” Document objective findings: oxygen saturation levels, wound stage and dimensions, specific range-of-motion measurements, or the patient’s inability to perform particular daily activities without the device.
The duration of need — six weeks, three months, lifetime, or another specific timeframe.⁴
Height and weight if applicable to the equipment.
The physician’s NPI and license number.

The quality of this section decides whether the request moves or stalls. Reviewers measure the narrative against §354.1039, which requires documentation that the equipment is needed to treat the patient’s specific condition in the home, not for general convenience.⁶

Signatures and the 90-Day Clock

The form needs two signatures. The prescribing physician or allowed practitioner signs Section B, and a representative of the DME or medical supply provider who is familiar with the patient also signs.⁷ Both signatures must be dated. Signature stamps and date stamps are not acceptable.⁴

Timing matters. The physician’s signature is valid for only 90 days before the initiation of services or the date of the prior authorization request. In chronic and stable situations, the form stays valid for up to six months from the physician’s signature date. A signature outside those windows means the form is expired and you must start a new one.⁷

The prescribing physician keeps the original signed and dated form in the patient’s medical record. The DME provider keeps a copy for the same patient in their own records.

How to Submit and What to Expect

The completed, signed form goes to TMHP for prior authorization before any equipment is delivered. You have two options:

Fax the form and any supporting clinical documentation to (512) 514-4209.⁴
Submit through TMHP’s approved electronic methods, including PA on the Portal at tmhp.com. If you submit electronically, you still have to retain a signed and dated copy in the patient’s medical record at your place of business.⁷

TMHP processes requests by date received. A complete, legible, properly signed request can be processed in as few as three business days.¹ On approval, the system assigns an authorization number to use when billing for the equipment. Delivering equipment before you have that number is a risk: if prior authorization was required and either was never submitted or was denied, the claim will not be paid.

If TMHP Asks for More Information

When TMHP receives a request with missing, incomplete, or illegible information, the prior authorization department contacts the requesting provider. TMHP makes a minimum of three attempts before escalating.¹

You have 14 business days from the date TMHP received the original request to supply the missing information. Miss that window and the request is denied as incomplete, and you start over. TMHP also sends the patient a letter about the status of the request. The fastest way to avoid this is to double-check every field and attach supporting clinical notes with the first submission.

Why Forms Get Rejected

Most problems with this form come down to a short list of recurring mistakes:

The physician signed more than 90 days before the prior authorization request or the start of services.
The DME provider representative never signed alongside the physician.
A signature stamp or date stamp was used instead of an actual signature.
The medical necessity narrative is vague — “patient needs wheelchair” — with no documented functional limitations, diagnosis, or clinical measurements.
The patient was last seen more than six months before the form was signed.
Section B justifications reference the wrong item numbers, so reviewers cannot match equipment to diagnoses.
HCPCS codes or quantities are missing.

Catching these before faxing saves weeks. The 14-business-day response window on an incomplete request is not generous.

Appealing a Denial

If prior authorization is denied, the patient has the right to request a fair hearing. The deadline is 90 calendar days from either the effective date of the denial or the date on the notice of adverse action, whichever is later.⁸

To keep existing DME services in place during the appeal, the patient must request the hearing before the effective date of the denial shown on the notice. A request filed after that date may mean services are interrupted while the appeal runs. If the original denial is upheld after the hearing, the agency can seek to recover the cost of any services that continued solely because of the appeal.

1
Texas Medicaid & Healthcare Partnership. Fee-for-Service Prior Authorizations
2
Texas Medicaid & Healthcare Partnership. Forms
3
Texas Medicaid & Healthcare Partnership. Claims Filing
4
Texas Medicaid & Healthcare Partnership. Home Health Services Title XIX DME Medical Supplies Prescribing Provider Order Form Instructions
5
Centers for Medicare & Medicaid Services. National Provider Identifier Standard
6
Texas Administrative Code. 1 Texas Administrative Code 354.1039 – Benefits and Limitations of Home Health Services
7
Texas Medicaid & Healthcare Partnership. Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook
8
Texas Health and Human Services. Submitting a Fair Hearing Request Summary