Provider Alert! TCHP Prior Authorization RequirementsTexas Children's Health Plan
Date: July 1, 2019
Subject: TCHP Prior Authorization Requirements
Effective October 1, 2019, TCHP has updated the prior authorization listing. Please note there are some key changes for providers.
Case by Case Added Services
This category includes CPT/HCPCS codes that are listed as not payable in the TMHP fee schedule.
Clinician Administered Drugs that Require Authorization
Please refer to the Prior Authorization Reference Information document for specific codes that fall under this category.
This document can be found at:
DME Repair (K0739) when greater than 35 units
Miscellaneous DME (E1399) when billed amount is greater than $500
These items are no longer listed separately as they now fall into the category of Clinician Administered Drugs that Require Authorization.
These services will continue to require prior authorization.
- Botulinum Toxin Injections
- High cost (>$50,000) injectable drugs in the outpatient setting (e.g. nusinersen, kymriah, exondys 51), excluding FDA approved chemotherapy
- Hydroxyprogesterone caporate injections
- Non-FDA Approved Medications
The new TCHP prior authorization list and our latest search & find companion guide will also be posted at: https://www.texaschildrenshealthplan.org/for-providers/provider-resources
If there are further questions, please contact the Provider Relations Department at 800-731-8527.