Articles with relevant information for Primary Care Providers (PCP).
New claim appeal form can be found at http://www.texaschildrenshealthplan.org/for-providers/resources/downloadable-forms Please note that providers must file an appeal within 120 days from the date of the denial for reconsideration.
A common reason for behavioral health readmission is delay to an outpatient supply of antipsychotic medications. You can help avoid this problem by completing prior authorization documentation before a patient is discharged. Texas Children’s Health Plan follows Texas Medicaid Guidelines for the use and approval of antipsychotics in children. Prior authorization documentation for antipsychotic medications can be found here: https://www.navitus.com/Misc-Pages/PDF-Form-Viewer.aspx?FormID=5264d812-b3d9-45f7-9b7a-a48eefca8adc Providers can ensure patients receive antipsychotic medications at discharge by using the hospital pharmacy or a community pharmacy delivery service. If a patient...
Effective for dates of service on or after September 1, 2017, physical therapy (PT), occupational therapy (OT), and speech therapy (ST) benefits for all ages will change for Texas Medicaid. Please review this link for changes to this medical benefit policy that applies to the following: Billing structure changes for PT, OT, and ST services Procedure codes end-dating August 31, 2017 Required modifiers Claims filing changes Clarification to benefits Providers may refer to the current Texas Medicaid Provider Procedures Manual, Physical Therapy, Occupational Therapy, and Speech Therapy...
On April 20, 2017 the US Food and Drug Administration (FDA) issued a statement that CODEINE is CONTRAINDICATED for treatment of pain or cough for children under 12 years. The also WARN against its use in adolescents 12-18 years old, especially those with obesity, obstructive sleep apnea, or severe lung disease. The FDA considers TRAMADOL to be CONTRAINDICATED for children younger than 18 to treat pain from tonsillectomy or adenoidectomy. Note that Tramadol is not FDA approved for use in...
Oral corticosteroids have been shown to definitively benefit children with moderate to severe asthma exacerbations. However, they show no benefit and even possible harm for children with minimal-to-mild exacerbations. Recent research using data from Texas Children’s Health Plan has found very high rates of oral corticosteroid dispensing in the past year for children with a diagnosis of asthma: close to 50% for children under 5 years, and close to 40% of children over 5 years. There was large variation in...
Tired of faxing authorization requests and medical records? Spending too much time on hold waiting to speak to an Authorization Specialist for non-urgent authorization request? Looking for a faster, more efficient way to submit authorizations? Why not submit your authorizations request through Clear Coverage? What are the benefits? Easy to access 24/7 online access to Clear Coverage Receive real time authorization status by viewing your office’s home page in Clear Coverage Services are immediately uploaded into Texas Children’s Health Plan’s authorization for clinical review Automatic APPROVALS may be...
Attention STAR Kids Providers May 17, 2017 Authorization Extension for STAR Kids Members The Health and Human Services Commission expects managed care organizations to extend long term services and supports (such as Personal Care Services, Community First Choice, and Private Duty Nursing) authorizations for services until completion of the STAR Kids Screening and Assessment Instrument (SAI), but no longer than July 1, 2017. In order to receive payment for these services, you must have authorization from Texas Children’s Health Plan, and the SAI must be completed by...
Oral Corticosteroids have been shown to have definite benefit for children with moderate to severe asthma exacerbations, but no benefit and possible harm for minimal to mild exacerbations. Recent research using data from Texas Children’s Health Plan has found very high rates of oral corticosteroid dispensing in the prior year for children with a diagnosis of asthma – close to 50% for children under 5 years, and close to 40% of children with asthma over 5 years. There was large...
Pharmacy Prior Authorizations (PAs) can be a difficult administrative burden for providers and staff, however, they help ensure patients are receiving the most evidence-based, cost-effective medications. The Vendor Drug Program (VDP) is the state resource for the Texas Medicaid formulary and Preferred Drug List (PDL). VDP has provided a very helpful guide to managing pharmacy benefits for your patients. You can access this resource here: http://casestudies.txhealthsteps.com/stepsQuickCourses/prescribers/ This Quick Course reviews the following: Searching Formulary for prescription and OTC drugs Checking the Preferred Drug List...
Texas Children’s Health Plan is excited to announce the upcoming implementation of Clear Coverage for inpatient authorization requests beginning May 1, 2017. Clear Coverage is a web-based system that provides an automated method for providers and health plans to manage authorizations for inpatient services at the point of decision. Clear Coverage enables automated authorization, notification, eligibility and direction of members to in-network service providers. Clear Coverage provides the following benefits: Providers have immediate access to coverage, medical appropriateness and network rules,...
