Provider Alert! Prior Authorization Guideline updates for Private Duty Nursing (PDN) and therapy specialty services

Attention: All Providers
Effective Date: July 18, 2020 for PDN and August 11, 2020 for therapy Services

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: TCHP would like to inform you of recent updates to the prior authorization requirements and the effective dates. Updates include the following:
Private Duty Nursing, effective July 18, 2020

• Nursing notes are no longer required but are recommended for medical necessity determination.
• The request can now be submitted within 60 days of end date of the current authorization.
• The member needs a treating provider visit at least every year (or every 365 days). This requirement is waived during the COVID disaster declaration period.

Physical therapy, occupational therapy speech therapy, effective August 11, 2020

• Providers may submit a prior authorization or service authorization request for services at least 60 Days prior to the expiration of the current authorization period.
• For change of coverage due to MCO transfers and Continuity of Care, the authorization request will not be considered retrospective if submitted within the same month of the enrollment date.

How this impacts providers: Providers should follow the new prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days.

Next steps for providers: Update their office staff of the new authorization requirements.

Resources:

Prior authorization form
TCHP prior authorization information 

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.