Tag - Prior Authorization

Provider Alert!
25Jul

Provider Alert! Updated Prior Authorization Criteria for Therapy with Burosumab-Twza (Crysvita)

Date: July 25, 2024 Attention: All Providers Effective date: July 1, 2024 Call to action: Texas Children’s Health Plan’s prior authorization (PA) criteria for renewal or continuation therapy with burosumab-twza (Crysvita) has changed, effective for dates of service on or after July 1, 2024. TCHP’s criteria for determining medical necessity for renewal or continuation therapy with burosumab-twza (Crysvita) is aligned with Texas Medicaid policy, as outlined in Texas Medicaid Provider Procedures Manual including the following update: Clinical documentation from the physician must confirm that the...

By OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , , 0 CommentsRead more...
Provider Alert!
25Jul

Provider Alert! Updated Prior Authorization Criteria for Elevidys

Date: July 24, 2024 Attention: All Providers Effective Date: September 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that Texas Health and Human Services Commission (HHSC) updated the prior authorization criteria for Elevidys (procedure code J1413), a benefit of Medicaid and CHIP, as the result of a recent review by the FDA. The update is effective September 1, 2024, for fee-for-service Medicaid clients. Elevidys (delandistrogene moxeparvovec-rokl) is an adeno-associated virus vector-based gene therapy indicated for the treatment of...

By OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , , 0 CommentsRead more...
Provider Alert!
24Jul

Provider Alert! Update to Recertification or Extension Prior Authorization Requests for Nusinersen (Spinraza)

Date: July 23, 2024 Attention: All Providers Effective date: July 1, 2024 Call to action: The purpose of this communication is to inform providers that effective for dates of service on or after July 1, 2024, recertification and extension prior authorization requests for nusinersen (Spinraza) will be subject to medical director review for additional 12-month periods. How this impacts providers: Providers should reference the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.10.1.2 “Recertification/Extension Requests (for all Antisense Oligonucleotides),” for additional recertification...

By HHSC, OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , , 0 CommentsRead more...
Provider Alert!
06Jun

Provider Alert! Update to Age Requirement for Prior Authorization of Inotuzumab Ozogamicin (Besponsa)

Date: June 6, 2024 Attention: All Providers Effective for dates of service on or after: July 1, 2024 Call to action: The purpose of this communication is to inform providers that effective for dates of service on or after July 1, 2024, the age requirement for prior authorization of inotuzumab ozogamicin (Besponsa) (procedure code J9229) will be expanded to include pediatric and adult clients who are one year of age or older. How this impacts providers: Providers should reference the current Texas Medicaid Provider...

By Facilities, OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , , 0 CommentsRead more...
Provider Alert!
28May

Provider Alert! Implementation of Hormonal Therapy Agents Clinical Prior Authorization

Date: May 28, 2024Attention: All Providers Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that on May 17, 2024 Health and Human Services Commission (HHSC) published an updated Hormonal Therapy Agents Clinical prior authorization criteria guide that was originally implemented on March 1, 2024. Previous TCHP provider alerts on hormonal therapy agents: Clinical Implementation of Hormonal Therapy Agents Clinical Prior Authorization Effective March 1, 2024: https://www.thecheckup.org/2024/02/02/provider-alert-clinical-implementation-of-hormonal-therapy-agents-clinical-prior-authorization-effective-march-1-2024/ Clinical Criteria Implementation for Enzyme Replacement Hormonal Therapy Agents effective May 1, 2024:...

By Facilities, OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , 0 CommentsRead more...
Provider Alert!
07May

Provider Alert! Prior Authorization Update for Incontinence Supplies Procedure Code A6250

Date: May 7, 2024 Attention: All Providers Effective: April 10, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of a prior authorization update for incontinence supplies procedure code A6250, skin sealants, protectants, moisturizers, and ointments, any type, any size. Procedure code A6250 is indicated to treat the following: Incontinence-associated dermatitis Effective April 10, 2024, prior authorization is required for procedure code A6250 for members 0-3 years of age. Providers can review prior authorization criteria and additional information regarding procedure code A6250...

By OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , 0 CommentsRead more...
Provider Alert!
26Apr

Provider Alert! Change in Preferred Drug List Status for Antihyperuricemics Drug Class

Date: April 25, 2024 Attention: All Providers Effective date: April 22, 2024 Call to action: Effective April 22, 2024, the Texas Health and Human Services (HHS) removed non-preferred status from brand name Mitigare products. This is in response to the discontinuation of the brand products Colcrys by the manufacturer. The preferred status of the brand name Colcrys will not change to allow any remaining stock to be used. How this impacts providers: The change will allow providers to prescribe the generic without requiring PDL prior...

By OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , , 0 CommentsRead more...
Provider Alert!
04Apr

Provider Alert! New Prior Authorization Resource to Determine Dates of Service

Date: April 3, 2024 Attention: All Providers Call to action: The purpose of this communication is to inform providers of a new resource available from Texas Medicaid and Healthcare Partnership (TMHP) available at https://www.tmhp.com/topics/prior-authorization/pa-calculator.  It is included on the TMHP prior authorization webpage. Providers are encouraged to utilize this calculator to calculate the dates of service that must be applied to the prior authorization form/prior authorization request.  By accessing TMHP’s tool, providers will save time and avoid having to resubmit or correct authorizations...

By OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, 0 CommentsRead more...
Provider Alert!
22Mar

Provider Alert! Sleep Studies no longer require Prior Authorization

Date: March 22, 2024 Attention: All Providers Effective date: February 7, 2024 Call to action: Effective for dates of service on or after February 7, 2024, Texas Children’s Health Plan (TCHP) will not require a prior authorization for sleep studies. Disclaimer: It is the responsibility of the Provider to verify that a service is a benefit of Texas Medicaid for service codes that TCHP does not require prior authorization. Services rendered by out-of-network providers will require prior authorization. TCHP would like to remind providers that...

By OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, 0 CommentsRead more...
Provider Alert!
27Feb

Provider Alert! Coverage of Elevidys Begins January 2024

Date: February 27, 2024 Attention: All Providers Prior authorization effective date: February 1, 2024 Call to action: The purpose of this communication is to inform providers that on January 1, 2024, Elevidys became a benefit of Medicaid and CHIP. Texas Health and Human Services Commission (HHSC) requires prior authorization for Elevidys (procedure code J1413) for Medicaid and CHIP, effective February 1, 2024. Elevidys is an adeno-associated virus vector-based gene therapy indicated for the treatment of ambulatory pediatric clients ages 4 through 5 years with...

By Facilities, OB/GYNs, Office Managers, Pharmacy, Primary Care Providers, Provider Alert, Specialists, , , 0 CommentsRead more...