Provider Alert! COVID-19 Disaster Declaration – ALERT #5 – Prior Authorization Adjustments

Provider Alert! COVID-19 Disaster Declaration – ALERT #5 – Prior Authorization Adjustments

Date: November 21, 2022

Attention: All Providers

Effective Date: October 25, 2022

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: In response to the COVID-19 Disaster Declaration and in accordance with Texas Health and Human Services Commission, Texas Children’s Health Plan (TCHP) extends the following changes to our authorization procedures on new and initial prior authorizations until November 30, 2022:

EFFECTIVE March 18, 2020 AND NOW EXTENDED UNTIL November 30, 2022:

Out of Network (OON) Primary Care:

Waiver of prior authorization requirements for Out of Network office visits to PCPs is limited to Pediatrician, Family Practice/General Practice, Internal Medicine, Obstetrics and Gynecology.

EFFECTIVE APRIL1, 2020 AND NOW EXTENDED UNTIL November 30, 2022:

Retrospective Prior Authorization Requests:

TCHP may accept prior authorization requests submitted within seven (7) calendar days of the requested service start date.

  • Requests are subject to medical necessity review from the start date of service.
  • Requests received after seven (7) calendar days of the requested service start date will be processed per TCHP’s retrospective review procedure.

EFFECTIVE DECEMBER 1, 2020 AND NOW EXTENDED UNTIL November 30, 2022: 

Physician Signatures:

Waiver of prior authorization documentation requirement for timely signatures from physicians / providers when impacted by COVID-19.

  • Request MUST state—“Missing signatures, COVID-19.”
  • Medical necessity documentation MUST be submitted

EFFECTIVE JANUARY 5, 2022, EXTENDED UNTIL November 30, 2022: 

Out of Network (OON) Outpatient Behavioral Health (BH) Care:

Waiver of prior authorization requirements for the following Out of Network BH services:

  • Outpatient visit for psychiatric evaluation
    • Texas Medicaid guidelines limitation of one (1) psychiatric evaluation per year applies
    • Prior Authorization requirements for ordered BH services remain in place and are subject to medical necessity review.
    • See TCHP Prior Authorization List for BH services requiring prior authorization. This list is available on the Prior Authorization Information webpage at https://www.texaschildrenshealthplan.org/for-providers/provider-resources/prior-authorization-information. Providers should regularly check this list for the services requiring a prior authorization as it is subject to change.
  • Ongoing BH clinician outpatient visits for medication management
  • Outpatient psychotherapy visits
    • Prior authorization requirements apply for visits in excess of 30 per year

HOW THIS IMPACTS PROVIDERS

Relaxed prior authorization requirements as detailed above decrease administrative burden and increase access and timely service authorizations for members.

With the exception of the temporary prior authorization adjustments detailed above, TCHP’s prior authorization processes are otherwise unchanged.

Providers should continue to:

  • Request prior authorization for any medically necessary service listed on TCHP’s Prior Authorization List.
  • Submit required prior authorization forms and include the necessary information for processing:
    • procedure and diagnosis codes or description
    • applicable modifiers
    • dates of service
    • numerical quantities for services requested
  • Complete forms to the greatest extent possible and document when a COVID-19 related issue(s) prevents the provider from being able to submit any required document.
  • Submit clinical records to support medical necessity, including patient status, progress specific to some services (when applicable) and documentation such as but not limited to:
    • Letters of medical necessity
    • Progress notes
    • Therapy evaluations and re-evaluations
    • Nursing plans of care and notes
    • Seating assessments
  • Be aware that hearing screening requirements remain waived for speech therapy authorization requests.

THIS COVID-19 DISASTER EXTENSION DOES NOT APPLY TO THE FOLLOWING:

Ninety (90) day extensions of existing prior authorizations and service authorizations that require

recertification: This was in effect April 3, 2020 through December 31, 2020.

  • This is no longer effective as of January 1, 2021.

Prior authorization extensions for targeted case management: This was in effect April 20, 2020 through December 31, 2020.

  • Extensions are no longer effective as of January 1, 2021.
  • Targeted Case Management does not require prior authorization as of August 22, 2022.

Prior Authorization requirement for documentation of a change of provider letter is NO LONGER waived effective December 1, 2020.

  • A change of provider letter per request of the provider or member is required for prior authorization requests for services with dates of service overlapping an existing authorization.

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

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

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