Provider Alert! Positive Pressure Airway (PAP) device guideline

Attention: All Providers

Effective Date: June 17, 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 guidelines for home health, speech therapy, and positive pressure airway (PAP) devices. Updates include the following:

• Home health guideline:
  • Section 9. The length of the prior authorization is determined on an individual basis and based on the goals and timelines identified by the physician, provider, and client or responsible adult.
  • Home Health Services may be authorized for up to six months at a time. This is a change from 60 days – will allow for longer certification periods.
    Reference: home health guideline
• Speech therapy guideline:
  • Section 13. The following services are a benefit for STAR members only:
    • 1 Effective June 1, 2020, chronic speech therapy is a benefit for STAR members who are 21 years of age and older. This benefit is to allow for a new Speech Language Pathology (SLP) provider type. Previously, chronic speech therapy was not a benefit for any members over age 21.
    • 2 Speech therapy provided in the home is a benefit for STAR members who are 21 years of age and older.
      Reference: speech therapy guideline
  • Positive Pressure Airway (PAP) device guideline:
    • Section 5. Effective June 17, 2020, authorization duration has been extended to 12 months from 10 months to follow guidance from Texas Medicaid Provider Procedures Manual (TMPPM).
      A continuous positive airway pressure (CPAP) device or a Respiratory Assistance Device (such as BiPAP S) without a set backup rate will be considered purchased after 12 months of rental through the same provider. A request for purchase or further rental will not be considered.
    • New Section 7.3 Effective September 17, 2020, criteria for heated humidification will follow guidance from TMPPM. Providers must include documentation of medical necessity in the authorization request and documentation must support why heated humidification is medically necessary.
      • 7.3.1 Clinical signs and symptoms that may indicate heated humidification is medically necessary include the following:
      • 7.3.1.1 Dry, nonproductive cough
      • 7.3.1.2 Increased airway resistance
      • 7.3.1.3 Increased incidence of infection
      • 7.3.1.4 Increased work of breathing
      • 7.3.1.5 Complaint of substernal pain and airway dryness
      • 7.3.1.6 Thick, dehydrated secretions
      • 7.3.1.7 Receiving mechanical ventilatory support via tracheostomy

Reference: PAP device guideline

How this impacts providers: Providers should become familiar with the updates to the guidelines.

Next steps for providers: Inform their office staff of the guideline updates.

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.