Provider Alert! Update: Updates to Prior Authorization Requirements

Attention: All Providers

Effective Date: June 4, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. 

Call to action: TCHP would like to inform you of recent updates to the prior authorization requirements and the effective dates. Updates include the following: 

• Medical services now requiring prior authorizations: 
  • Therapeutic Continuous Glucose Monitors- effective April 1, 2020 
  • Secretion and Mucous clearance devices– effective June 3, 2020 with a new guideline available online.  
  • Electrical bone growth simulators (codes E0747 and E0748)- effective September 4, 2020 and will follow the Texas Medicaid Providers Procedure Manual (TMPPM) prior authorization criteria.  
  • Continuous glucose monitors are now a benefit of Texas Medicaid, effective April 1, 2020 and will follow the TMPPM prior authorization criteria.
     
• Corrections to prior authorization requirements: 
  • Bariatric surgery removed from CHIP as it is not a benefit of CHIP
     
• Organization of Behavioral Health authorization requirements: 
  • Behavioral Health Psychological/Neuropsychological Testing out of network services 
    •  Mental health: 
    • Inpatient 
    • Residential Treatment 
    • Partial Hospitalization Program 
    • Intensive Outpatient Program 
    • Outpatient Psychotherapy Visits (Greater   than 30 Visits per year) 
    • Mental Health Rehabilitation Services and Targeted Case Management (TCM) 
    • Skills Training 
  • Substance Abuse Disorder Treatment: 
    • Inpatient Detoxification 
    • Residential Treatment 
    • Partial Hospitalization Program 
    • Intensive Outpatient Program 
    • Outpatient Services

How this impacts providers: Providers should follow the new prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days.  

Prior Authorization Fax Lines 

• Medical Services Fax Line – 832-825-8760 or Toll-Free 1-844-473-6860 
  • Behavioral Health Services Fax Line – 832-825-8767 or Toll-Free 1-844-291-7505 

• LTSS and Private duty Nursing Fax Line – 346-232-4757 or Toll-Free 1-844-248-1567 

Prior Authorization Determinations 

The Utilization Management department processes service requests in accordance with the clinical immediacy of the requested services. 

Post hospital discharge services and supplies- within one business day after receipt of request.  

Next steps for providers: Update their office staff of the new authorization requirements. 
Resources: 

Prior authorization form 

TCHP prior authorization information 
 

Provider alerts related to the authorization information mentioned above: 

http://www.thecheckup.org/2020/04/02/provider-alert-therapeutic-continuous-glucose-monitors-become-benefit-of-texas-medicaid/ 

http://www.thecheckup.org/2020/04/02/provider-alert-secretion-and-mucous-clearance-devices/  

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org. 

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.