Tag - Prior Authorization

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 [...]

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 [...]

Texas Standard Prior Authorization Form

Texas Children’s Health Plan prefers the submission of the Texas Standard Prior Authorization form for prior authorization requests, excluding LTSS services. Requests should also include supporting clinical documentation as per the Texas Children’s Health Plan Authorization Guidelines. The form is available on the Texas Children’s Health Plan website at http://www.texaschildrenshealthplan.org/for-providers/resources/downloadable-forms.

Provider Alert! TCHP Prior Authorization Requirement

Subject: TCHP Prior Authorization Requirement Effective April 1, 2018, TCHP will be updating the prior authorization listing. This notice will serve as your 90-day advance notification of the change. Please note there are some key changes for providers. Removed from the list and will no longer require prior authorization: Walkers Vision Care, medically necessary New to the list: High cost injectable drugs (>$75K per dose) in an outpatient level of care require prior authorization. Examples include: Kymriah, Spinraza, Exondys Updates: Progesterone therapy has been updated to Hydroxyprogesterone caproate [...]

Reminder on obtaining an authorization for genetic testing

Quest Diagnostics is the exclusive contracted lab for TCHP. For OB providers, all genetic testing requires prior authorization. Link to all services that require prior authorization: http://www.texaschildrenshealthplan.org/sites/default/files/pdf/Pre-Certification%20Requirements%20JULY%202017.pdf

Provider Alert! Changes to physical, occupational and speech therapy benefits for all ages

Effective for dates of service on or after September 1, 2017, physical therapy (PT), occupational therapy (OT) and speech therapy (ST) benefits for all ages will change for Texas Medicaid. Please visit the TMHP website to review for changes to this medical benefit policy that applies to the following: Billing structure changes for PT, OT and ST services Procedure codes end-dating August 31, 2017 Required modifiers Claims filing changes Clarification to benefits Providers may refer to the current Texas Medicaid Provider Procedures Manual, Physical Therapy, Occupational [...]

Prior Authorization of Texas Health Steps (THSteps) dental therapy under general anesthesia for members who are six years of age or younger

Effective July 1, 2017, Texas Children’s Health Plan will be required to implement prior authorization for Level 4 deep sedation and general anesthesia provided in conjunction with therapeutic dental treatment for Medicaid dental clients from ages 0 through six years. All Level 4 services must be authorized prior to rendering services. Anesthesia services provided by a dentist should use procedure code D9223. Any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified registered nurse anesthetist (CRNA), should use procedure code [...]

Provider Alert! Benefit Changes Prior Authorization Update

Attention: All Texas Children’s Health Plan Providers Subject: UPDATE to Changes for Physical, Occupational, and Speech Therapy Benefits   Prior Authorization Changes Update Changes to TCHP Prior Authorizations for PT, OT, and ST services: For therapy authorizations with approved dates of service spanning the 9/1 transition date, TCHP created a revised authorization in our system that reflects the new billing structure using the same authorization number. For all therapy requests that were submitted prior to 9/1, the revised authorization will start on 9/1 and cover through the end [...]