Provider Alert! Prior Authorization Update for Botulinum Toxin Benefits with Diagnosis Restrictiontcph
Date: May 20, 2021
Attention: All Providers
Effective Date: May 18, 2021
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: Texas Children’s Health Plan (TCHP) would like to remind providers of the prior authorization requirements for Botulinum Toxin effective October 1, 2020. A prior authorization is no longer required when billed with one of the approved diagnosis codes that can be found here.
Update effective May18, 2021: The US Food and Drug Administration (FDA) approved BOTOX (procedure code J0585) for the treatment of neurogenic detrusor over activity (NDO) in pediatric patients five years of age and older who have an inadequate response to or are intolerant of anticholinergic medication.
HHSC will add diagnosis code N31.9 (Neuromuscular dysfunction of bladder, unspecified) for NDO in pediatrics clients.
How this impacts providers: A prior authorization is only required when procedure codes are not billed with one of the allowable diagnosis codes.
Next steps for providers: Providers should share this prior authorization update with their staff.
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers