Tag - Prior Authorization

Provider Alert!

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...

Provider Alert!

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:...

Provider Alert!

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...

Provider Alert!

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...

Provider Alert!

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...

Provider Alert!

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...

Provider Alert!

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...

Provider Alert!

Provider Alert! HCPCS and CPT Code Prior authorization Update

Date: February 26, 2024 Attention: All Providers Effective date: January 1, 2024 Call to action: The purpose of this communication is to offer information about the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) prior authorization updates. Resource: https://www.tmhp.com/sites/default/files/file-library/resources/rate-and-code-updates/hcpcs-updates/2024-hcpcs-special-bulletin.pdf How this impacts providers: Effective January 1, 2024 Texas Children’s Health Plan’s (TCHP's) prior authorization updates are listed below. These changes follow guidance from Texas Medicaid and Healthcare Partnership (TMHP). Medical necessity criteria for utilization review will be in accordance with Texas Medicaid...

Provider Alert!

Provider Alert! Enzyme Replacement Therapy Prior Authorization Update

Date: February 26, 2024 Attention: All Providers Effective date: February 1, 2024 Call to action: Texas Children’s Health Plan would like to make providers aware of prior authorization updates for certain enzyme replacement therapies. In alignment with Texas Medicaid Provider Procedure Manual (TMPPM) requirements, effective for dates of service on or after February 1, 2024, prior authorization will be required for enzyme replacement therapy velmanse alfa-tycv (Lamzede), procedure code J0217, and pegunigalsidase alfa-iwxj (Elfabrio), procedure code J2508. Prior Authorization Requirements include the following: Velmanse alfa-tycv...

Provider Alert!

Provider Alert! Reminder: Prior Authorization Form Completion

Date: February 13, 2024 Attention: All Providers Call to action: Texas Children’s Health Plan (TCHP) supports the guidance from Texas Health and Human Services Commission (HHSC) on rejecting the Prior Authorization (PA) received with incomplete or insufficient documentation per Uniform Managed Care Manual (UMCM), Chapter 3.22. ‘Essential Information’ is the information required to initiate the PA review process, and are as follows: Member name Member number or Medicaid number Member date of birth Requesting provider name Requesting provider’s National Provider Identifier (NPI) Service requested – Current Procedural Terminology (CPT),...