Provider Alert! Reminder of Therapy Benefits and Services Requiring a Prior Authorization

Attention: Primary Care, Therapy Providers, and Sub-specialties

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: Texas Children’s Health Plan (TCHP) would like to remind network providers of therapy benefits and those services that require a prior authorization.

Benefit:

• Physical therapy and occupational therapy provided in the home are a benefit.

Not benefits:

• Speech therapy for adult members over 21 years of age provided in the home is not a benefit per Texas Medicaid Provider Procedures Manual (TMPPM).
• Chronic speech, physical, and occupational therapy for adult members, over 21 years of age is not a benefit.
• Aquatic therapy, code 97113 is not a benefit in the home.

After two 60 day authorized periods, any continued requests for therapy services must be considered under the chronic therapy sections of the applicable guideline.

The following codes are non-payable per the Texas Medicaid fee schedule and will not be authorized for therapy:

• G0151-home physical therapy
• G0152- home occupational therapy
• G0153- home speech therapy

Physical Therapy Codes Payable and on the Prior Authorization List:

Occupational Therapy Codes Payable and on the Prior Authorization List:

Speech Therapy Codes Payable and on the Prior Authorization List:

• 92507
• 92508
• 92526
• 92620

How this impacts providers: Providers should follow the prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days. TCHP prior authorization information including guidelines are available here: https://www.texaschildrenshealthplan.org/for-providers/provider-resources/prior-authorization-information

Next steps for providers: Providers should inform their staff of the benefit coverage and prior authorization requirements.

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.