Monthly Archives - September 2018

Provider Alert! Authorization and Verification Process Updates

Subject:   Authorization and Verification Process Updates   Texas Children’s Health Plan (TCHP) has made updates to the authorization process. The following outlines a summary of the changes.   Individual Member Fax Requests To ensure Health Insurance Portability and Accountability Act (HIPAA) compliance, providers must send one fax request per member with each fax having its own cover sheet. Requests received with multiple members per fax will be returned to the provider and not processed.   Minimum Information Required to Process a Request *Providers must use the Texas Standard [...]

What are Personal Care Services (PCS)?

Personal Care Services (PCS) is a Medicaid benefit to help clients with everyday tasks. These tasks are called activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Examples of ADLs are: Bathing Eating Going to the toilet Dressing Walking Examples of IADLs are: Laundry Light housework Fixing meals To get PCS, a patient must: Be 0 years to 20 years and receive Medicaid. Have a disability, physical or mental illness, or a health problem that lasts for a long time. Have a reason why his or her guardian cannot help [...]

Flu Protection Starts Now

Flu season is on its way and vaccinating continues to be the best way to protect ourselves and our patients against serious complications from the flu.[1] Patients under the age of 18 should be offered the flu vaccine during office visits, while those over the age of 18 also have the option of receiving it at pharmacies. While the AAP and CDC each support the use of LAIV4 for the 2018-19 influenza season with the goal of accomplishing adequate vaccination [...]

Protection for Two

Influenza vaccination is an essential element of pre-pregnancy, prenatal, and postpartum care because influenza can result in serious illness, including a higher chance of progressing to pneumonia, when it occurs during the antepartum or postpartum period. In addition to hospitalization, pregnant women with influenza are at increased risk of intensive care unit admission and adverse perinatal and neonatal outcomes. The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists recommend [...]

Clarification In Limitations of Allergen Immunotherapy

Based on recommendations of network providers, the immunotherapy preparation (CPT 95165) benefit has been modified to allow 80 units in 6 months. This will facilitate ease of payment for initial preparation of antigen mixture for new patients and is consistent with national guidelines. Subsequent to the initial preparation claim, Texas Children’s Health Plan anticipates immunotherapy preparation (CPT 95165) maintenance claims consistent with national guidelines. Billing Use of CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy [...]

Key Changes to TCHP Therapy Authorization Guidelines

When services were not prior authorized by Texas Children’s Health Plan, (through another MCO or TMHP) the authorization request must include: A copy of the previously approved authorization letter. All of the documentation that was sent in the original authorization request to the previous MCO or TMHP, including any physician orders that were used to determine the start of care. If the services requested do not meet TCHP criteria, the services will be honored for the shorter of 90 days or until [...]

Provider Alert! New Claims Requirements Effective September 1, 2018

Date: August 20, 2018 New Claims Requirements Effective September 1, 2018 Attention:  Network Providers   Billing taxonomy Per section 6.2.1 of the TMPPM Billing providers must submit the taxonomy number on all electronic claims with the exception of Medicare primary claims. Electronic claims without a billing taxonomy will be rejected.   Claim Requirement Electronic Claim Billing Provider Taxonomy Code (required on all claims) 2000A, PRV03   Ordering/Referring Provider Requirement For services that require an ordering/referring provider the NPI of the ordering/referring provider must be attested. Billing providers can verify an ordering/ [...]