Provider Alert! Immobilized Lipase Cartridges to Become a Benefit of Texas Medicaid

Attention: All Providers

Effective Date: March 1, 2021

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 inform network providers that effective for dates of service on or after March 1, 2021, immobilized lipase cartridges (procedure code B4105) will become a benefit of Texas Medicaid. Procedure code B4105 will be a benefit when provided by a medical supplier (durable medical equipment) providers in the home setting.

How this impacts providers: Prior Authorization Criteria

Immobilized lipase cartridges (Procedure Code B4105) will require prior authorization and may be considered with documentation of medical necessity indicating that the client meets all the following criteria:

• The client has exocrine pancreatic insufficiency.
• The client utilizes an enteral feeding pump.
• The client utilizes a compatible formula and the amount of formula (mL) the client is receiving daily is documented.

This code will have a limit of 2 cartridges per day and 62 per month, per Texas Medicaid Healthcare Partnership (TMHP) guidelines.

Resources: TMHP Notice last updated 12/31/2020

Standard Prior Authorization Form

Next steps for providers: Share this information with their staff and submit prior authorization requests in a timely manner, when applicable.

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.