Prior Authorization – The Checkup

29SepSeptember 29, 2023

Provider Alert! UPDATE: 2023-24 RSV Season and Synagis Prior Authorization Begins October 2

Date: September 28, 2023 Attention: All Providers Call to action: Vendor Drug Program (VDP) announced the 2023-34 RSV season in a notice published to TexConnect on September 21, 2023. HHSC has since revised Form 1321 to address using the new product, Beyfortus, during the season. UPDATE: Health and Human Services (HHSC) revised the Synagis Standard Prior Authorization Addendum (HHS Form 1321) to reflect Beyfortus use. How this impacts providers: Here is a link to the 1321 form. Next step for Providers: Providers should utilize the...

By Texas Children's Health PlanOB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsPrior Authorization, RSV, RSV Season, Synagis0 CommentsRead more...

27SepSeptember 27, 2023

Provider Alert! 2023-24 RSV Season and Synagis Prior Authorization Begins Oct. 2 For Lower South Texas

Date: September 26, 2023 Attention: All Providers Effective date: October 2, 2023 Call to action: Health and Human Services Commission (HHSC) will begin the 2023-24 Medicaid and CHIP-covered monthly prophylaxis for RSV on October. 2, 2023, for all counties in State Health Service Region 11. We will not open any other regions for Medicaid coverage of RSV prophylaxis at this time. Refer to the season schedule for each region's start and end dates. HHSC will continue working with the Texas Pediatric Society's task force to determine...

By Texas Children's Health PlanOB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsPrior Authorization, RSV, Synagis0 CommentsRead more...

19JulJuly 19, 2023

Provider Alert! Prior Authorization Updates for Neurostimulators and Neuromuscular Stimulators

Date: July 18, 2023 Attention: All Providers Effective date: July 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of a new prior authorization requirement effective July 1, 2023, for neurostimulators and transcutaneous electrical supply- CPT Code A4560. How this impacts providers: This prior authorization requirement aligns with the TMPPM and applies to all lines of business CHIP, STAR, and STAR Kids. There is a limit to one unit every 12 weeks or four units per year. Source: Texas...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsNeuromuscular Stimulators, Neurostimulators, Prior Authorization0 CommentsRead more...

19JulJuly 19, 2023

Provider Alert! Zynteglo® now a Medicaid and CHIP Benefit – Prior Authorization Effective September 1, 2023

Date: July 18, 2023 Attention: All Providers Effective Date: September 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective September 1, 2023, the Texas Health and Human Services (HHSC) will be implementing required prior authorization criteria for Zynteglo® (procedure code J3590) for Medicaid and CHIP. Zynteglo® became a benefit of Medicaid and CHIP on July 1, 2023. Zynteglo® (betibeglogene autotemcel) is an autologous stem cell-based gene-therapy indicated for treating adult and pediatric patients with...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsCHIP, gene therapy, medicaid, Prior Authorization, Zynteglo0 CommentsRead more...

13JulJuly 13, 2023

Provider Alert! Signature Updates to Home Health Prior Authorization Request Forms

Date: July 12, 2023 Attention: All Providers Effective date: July 1, 2023 Call to action: The purpose of this communication is to provide awareness that the signature requirements for Title XIX (Medicaid) Home Health Services have changed. Medicaid-enrolled physicians and allowed practitioners can now sign prior authorizations and order covered Medicaid Home Health Services, including skilled nursing, home health aide services, durable medical equipment and supplies, and adult physical and occupational therapy services. An allowed practitioner is a physician assistant (PA) or an advanced...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsHome Health Services, medicaid, Medicaid Services, Prior Authorization0 CommentsRead more...

20JunJune 20, 2023

Provider Alert! Prior Authorization Diagnosis Coding Reminder

Date: June 20, 2023 Attention: All Providers Call to action: As a reminder, Texas Children’s Health Plan (TCHP) aligns with the Texas Medicaid Provider Procedure Manual (TMPPM) regarding the ICD-10-CM diagnosis-coding requirement on claim submissions. Resource: TMPPM Section 6: Claims filing How this impacts providers: Diagnosis codes guidance as outlined in the TMPPM are as follows: Diagnosis codes must be to the highest level of specificity available Diagnosis codes must be appropriate for the age of the client as identified in the ICD-10-CM description of the...

By Texas Children's Health PlanHHSC, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsCoding, Diagnosis Codes, Prior Authorization0 CommentsRead more...

09MayMay 9, 2023

Provider Alert! Subject: Unclassified Medical Drugs Prior Authorization Requirement

Date: May 8, 2023 Attention: All Providers Effective Date: June 8, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective June 8 2023, medical claims under $5,000 submitted to TCHP with unclassified Healthcare Common Procedure Coding System (HCPCS) code J3490 will no longer require a pre-service (prior authorization) request as claims above this cost will be subject to clinical necessity review by the pharmacy team. This dollar limit does not apply to other unclassified codes J9999, J3590,...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsHCPCS, Prior Authorization, Unclassified Medical Drugs, VDP, Vendor Drug Program0 CommentsRead more...

25AprApril 25, 2023

Provider Alert! Lidocaine 5% Patch Added To PDL

Date: April 21, 2023 Attention: All Providers Effective Date: April 3, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective April 3, 2023, the Texas Health and Human Services Commission (HHSC) temporarily removed the non-preferred status from the generic product, Lidocaine 5% patches on the preferred drug list (PDL). The preferred status of the brand name products (NDC 63481-0687-06) will not change to allow for any existing stock available to be utilized. This is in response...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, Specialistslidocaine, PDL, Preferred Drug List, Prior Authorization0 CommentsRead more...

05JanJanuary 5, 2023

Provider Alert! Prior Authorization Criteria Update for Amvuttra

Date: December 29, 2022 Attention: All Providers Effective date: February 1, 2023 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: Effective, February 1,2023, the Texas Health and Human Services Commission (HHSC) will update the prior authorization criteria for Amvuttra (procedure code J0225). Amvuttra (vutrisiran) is a transthyretin-directed...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsAmvuttra, Amyloidosis, HATTR, Prior Authorization0 CommentsRead more...

28DecDecember 28, 2022

Provider Alert! Synagis Prior Authorization Guidance – Reminder

Date: December 28, 2022 Attention: All Providers 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: Beginning with the 2022-23 Human Respiratory Syncytial Virus (RSV) season, the Texas Health and Human Services Commission (HHSC) implemented simplified approval criteria for Synagis subsequent dosing (renewals). Pharmacies will no...

By Texas Children's Health PlanOB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsPrior Authorization, RSV, Synagis0 CommentsRead more...

Tag - Prior Authorization