Specialists

Articles with relevant information for Specialists.

Provider Alert! Nutritional Supplement Guideline Change

Effective 10/1/2018, Texas Children’s Health Plan will no longer require prior authorization for nutritional products for members 20 years and younger who: receive all or part of their nutritional intake through a tube as documented by ICD-10 codes (z43.1; z93.1, z93.4), OR have a metabolic disorder that has been documented with one of the diagnosis codes listed in the current TMPPM Section 2.2.17.2.2. Providers will retain the responsibility of maintaining appropriate documentation for the nutritional products supplied. A retrospective review may be [...]

Authorization and Verification Process Updates

Texas Children’s Health Plan has made updates to the authorization process. Individual Member Fax Requests To ensure Health Insurance Portability and Accountability Act (HIPAA) compliance, providers must send one fax request per member with each fax having its own cover sheet. Requests received with multiple members per fax will be returned to the provider and not processed. Minimum Information Required to Process a Request Providers must use the Texas Standard Prior Authorization Request Form*, which can be found at https://www.texaschildrenshealthplan.org/for-providers. Click on Downloadable [...]

What are Personal Care Services (PCS)?

Personal Care Services (PCS) is a Medicaid benefit to help clients with everyday tasks. These tasks are called activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Examples of ADLs are: Bathing Eating Going to the toilet Dressing Walking Examples of IADLs are: Laundry Light housework Fixing meals To get PCS, a patient must: Be 0 years to 20 years and receive Medicaid. Have a disability, physical or mental illness, or a health problem that lasts for a long time. Have a reason why his or her guardian cannot help [...]

Clarification In Limitations of Allergen Immunotherapy

Based on recommendations of network providers, the immunotherapy preparation (CPT 95165) benefit has been modified to allow 80 units in 6 months. This will facilitate ease of payment for initial preparation of antigen mixture for new patients and is consistent with national guidelines. Subsequent to the initial preparation claim, Texas Children’s Health Plan anticipates immunotherapy preparation (CPT 95165) maintenance claims consistent with national guidelines. Billing Use of CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy [...]

Key Changes to TCHP Therapy Authorization Guidelines

When services were not prior authorized by Texas Children’s Health Plan, (through another MCO or TMHP) the authorization request must include: A copy of the previously approved authorization letter. All of the documentation that was sent in the original authorization request to the previous MCO or TMHP, including any physician orders that were used to determine the start of care. If the services requested do not meet TCHP criteria, the services will be honored for the shorter of 90 days or until [...]

Upcoming Changes to Prior Authorization for Antipsychotic Medications

Effective September 1, 2018, the prior authorization for antipsychotic medications will change. At the May 15th Texas Association of Community Health Plans P&T Committee meeting, the Texas Managed Care Organizations, supported by Navitus, voted by majority to modify the Antipsychotic Clinical Prior Authorization Edit in compliance with the guidelines set forth by the Health and Human Services Commission Vendor Drug Program. The health plans opted to remove the requirements for diagnoses, while maintaining criteria for age and duplicate therapy [...]

Medication Synchronization Plan

Effective September 1, 2018, Texas Children’s Health Plan members can receive the Medication Synchronization benefit that will allow them to pick up all of their prescription medication refills on a single day each month, rather than having to go to the pharmacy multiple times per month. The coordination of refills is proven to lead to better adherence to medication regimens. Inform your patients about this exciting new option. Taking advantage of the Medication Synchronization benefit is as simple as the [...]

Clarification in Limitations of Allergen Immunotherapy

Based on recommendations of network providers, the immunotherapy preparation (CPT 95165) benefit has been modified to allow 80 units in 6 months. This will facilitate ease of payment for initial preparation of antigen mixture for new patients and is consistent with national guidelines. Subsequent to the initial preparation claim, Texas Children’s Health Plan anticipates immunotherapy preparation (CPT 95165) maintenance claims consistent with national guidelines. Billing Use of CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy [...]

Now available: Integrating Postpartum Depression Screening into Routine Infant Medical Checkups

Texas Health and Human Services has a new online training, available to Texas Health Steps providers, on integrating PPD screening into routine infant checkups. Texas Health Steps providers can receive separate reimbursement for conducting maternal PPD screening during an infant’s preventive medical checkup. Click here to learn more about the policy and connect with resources to help you implement it in your practice.