Provider Alert

Articles with information about Provider Alerts.

Provider Alert! Health Insurance Portability and Accountability Act (HIPAA) Compliant Reasons for Denials and Adjustments

Attention:  All Providers Health Insurance Portability and Accountability Act (HIPAA) Compliant Reasons for Denials and Adjustments   Beginning May 15, 2019, Texas Children’s Health Plan (TCHP) providers will see positive changes to their HIPAA standard 835 electronic remittance and paper explanations of payments (EOPs). TCHP will be providing more robust and HIPAA compliant messages by utilizing national standard claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs). What are CARCs and RARCs? CARCs and RARCs are industry standard code sets used to [...]

Provider Alert! Texas Children’s Health Plan Claim Editing System Update

Attention:  All Providers Reminder: Texas Children’s Health Plan Claim Editing System Update   Texas Children’s Health Plan (TCHP) previously sent a Provider Alert notifying providers that an intended transition to a new Claims Editing System (CES) by Optum was to occur in December 2018. Please be advised that this transition will now be occurring May 31, 2019.  Any claims submitted May 31, 2019 and after, including corrected and adjusted claims, will be processed with the Optum CES edits. TCHP is required by Texas [...]

Prior Authorization Reference Information

The Texas Children’s Health Plan website now has an additional resource for information related to prior authorization requirements. The Prior Authorization Reference Information documents the codes that require authorization for payment based on authorization category. This list is not yet all-inclusive. It can be found at: https://www.texaschildrenshealthplan.org/sites/default/files/pdf/PA%20Code%20List%20December%202018.pdf In addition, providers can submit an authorization request online for the codes listed on the Prior Authorization Reference Information document via Clear Coverage. For access to or training on the use of Clear [...]

Provider Alert! Governor Greg Abbott Issues Disaster Declaration for Cherokee, Freestone, Houston, Leon, Madison, Nacogdoches, Robertson, San Augustine, and Shelby Counties.

On April 18, 2019: Governor Greg Abbott issued a disaster declaration for the following counties Cherokee, Freestone, Houston, Leon, Madison, Nacogdoches, Robertson, San Augustine, and Shelby counties. If a member resides in one of these impacted areas named above Texas Children’s Health Plan will make every effort to assist them in obtaining medically necessary services. PHARMACY: Navitus Pharmacy update related to disaster declaration: Navitus has implemented the "Disaster Declaration and Refill Too Soon" process as a result of the severe weather, including thunderstorms and tornado [...]

Provider Alert! DME/Supplies Exceeding Medicaid Limitations

Date: 04/09/2019 Subject: DME/Supplies Exceeding Medicaid Limitations Attention: DME and Home Health Providers Texas Children’s Health Plan applies benefit limitations for DME Supplies and Equipment per the current TMHP Manual for all members eligible to receive the benefit. See benefit exceptions below. Frequency of Billing As a reminder, DME monthly limits will be applied every 27 days. Claims for recurring DME rentals and/or monthly disposable supplies billed prior to this renewal date are subject to denial. Denied claims may be appealed through the standard appeal [...]

Provider Alert! Update: Reimbursement Code for Sports and Camp Physicals

As spring training and sports begin, it’s an ideal time to ensure that all members are receiving their Texas Health Steps check ups timely. Texas Children’s Health Plan wants to remind our pediatric providers about sports physicals as value-added services. Members aged 5 - 19 (STAR & CHIP), 5 – 20 (STAR Kids) who have had a Texas Health Steps check up in the last 12 months will be eligible for one annual sports and school physical delivered by their [...]

Provider Alert! Prior Authorization

Prior authorization alert Effective January 1, 2019, Texas Children’s Health Plan updated the prior authorization listing. Please note there are some key changes for providers. Removed from the list and will no longer require prior authorization: Baclofen Pump New to the list: Home Telemonitoring Updates: Ambulance (non-emergent transport) has been updated to Non-Emergency Ambulance Transport. Augmentative Communication Device has been updated to Augmentative Communication Device and Accessories. Chemotherapy non-FDA approved has been updated to Non-FDA approved medications. Cranial Molding Orthosis (Helmets) has been updated to Cranial Molding Orthosis. High cost (>$50,000) [...]

Texas Standard Prior Authorization Request Form compliance grace period has ended

Starting January 1, 2019, the 90-day grace period for compliance with the exclusive use of the Texas Standard Prior Authorization Request Form has ended. From this date forward, providers must use the Texas Standard Prior Authorization Request Form, which can be found at https://www.texaschildrenshealthplan.org/for-providers. Click on Downloadable Forms on the left-hand side, then click Standard Prior Authorization Form or Behavioral Health Authorization Form to download. As a reminder, the following essential information is required to start the authorization process: Member Name, [...]

Provider Alert! Prior Authorization Alert

Effective January 1, 2019, Texas Children’s Health Plan updated the prior authorization listing. Please note there are some key changes for providers. Removed from the list and will no longer require prior authorization: Baclofen Pump New to the list: Home Telemonitoring Updates: Ambulance (non-emergent transport) has been updated to Non-Emergency Ambulance Transport. Augmentative Communication Device has been updated to Augmentative Communication Device and Accessories. Chemotherapy non-FDA approved has been updated to Non-FDA approved medications. Cranial Molding Orthosis (Helmets) has been updated to Cranial Molding Orthosis. High cost (>$50,000) injectable in [...]

Provider Alert! Follow-up on Billing Provider Taxonomy Claims Requirement Effective September 1, 2018

Clearing House Process Verification: Please verify with your clearing house that the TMHP attested billing provider taxonomy is being transmitted on claims for all products. Through collaborative work with provider groups, it has been identified that some clearing houses have been removing the billing taxonomy code on claims prior to submitting to the health plan for processing resulting in claims denials. Billing provider taxonomy is a requirement effective 9/1/2018. Because providers use a variety of clearing houses for claims submission, your [...]