Tag - Prior Authorizations

Prior Authorization Reference Information

The Texas Children’s Health Plan website now has an additional resource for information related to prior authorization requirements. The Prior Authorization Reference Information documents the codes that require authorization for payment based on authorization category. This list is not yet all-inclusive. It can be found at: https://www.texaschildrenshealthplan.org/sites/default/files/pdf/PA%20Code%20List%20December%202018.pdf In addition, providers can submit an authorization request online for the codes listed on the Prior Authorization Reference Information document via Clear Coverage. For access to or training on the use of Clear [...]

No Prior Authorizations Required for Texas Children’s Health Plan (TCHP) In-Network Observations

1. In-network Observation stays do not require prior-authorization. 2. Hospital stays that include less than two bed days (less than “two midnights”) at the time of submission will be categorized as Observation Level of Care with some exceptions: a. Obstetrical deliveries b. Patient deaths c. Against Medical Advice (AMA) discharges d. Intensive Care Unit (ICU) admissions e. Pediatric Intensive Care Unit (PICU) admissions f. Pediatric Progressive Care Unit (PCU) g. Initial Neonatal Intensive Care Unit (NICU) admissions h. Neonatal Intensive Care Unit (NICU) readmissions within 28 days i. Behavioral [...]

Need Help Navigating Pharmacy Prior Authorizations?

Pharmacy Prior Authorizations (PAs) can be a difficult administrative burden for providers and staff, however, they help ensure patients are receiving the most evidence-based, cost-effective medications. The Vendor Drug Program (VDP) is the state resource for the Texas Medicaid formulary and Preferred Drug List (PDL).  VDP has provided a very helpful guide to managing pharmacy benefits for your patients. You can access this resource here: http://casestudies.txhealthsteps.com/stepsQuickCourses/prescribers/ This Quick Course reviews the following: Searching Formulary for prescription and OTC drugs Checking the Preferred Drug [...]

Prevent Behavioral Health Readmissions

Prevent Behavioral Health Readmissions Poor access to prescribed medications after discharge is one of the most common reasons for behavioral health readmissions. One effective way to help ensure access to medications post-discharge is to obtain and verify prior authorization for the medications before discharge. Texas Children’s Health Plan follows the state of Texas Medicaid Guidelines for the use and approval of antipsychotics in children. Criteria for approval can be accessed here. If a patient does not meet criteria and the prior [...]