Provider Alert! Prior Authorization Requirements for Incontinence Suppliestcph
Date: March 15, 2021
Attention: All Providers
Effective Date: December 22, 2020
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 of the prior authorization requirements for incontinence supplies.
How this impacts providers: Incontinence supplies (diapers, wipes, and under pads) may be considered for members age 3 and younger and with a medical condition that results in increased urine or stool output beyond what is typical for this age group, including but not limited to:
- Short bowel syndrome, Chron’s disease, Celiac disease, Diabetes insipidus, Radiation enteritis, or certain metabolic conditions.
- Quantity limitations per TMPPM apply to this age group: diapers (240 per month), wipes (2 boxes per month), and underpads (120 per month).
- Wipes are for members receiving diapers/briefs/pull-ons and under pads are for members receiving diapers/briefs/pull-ons/liners/urine or bowel collection devices.
- Gloves used to change diapers and briefs are not considered medically necessary unless the member has skin breakdown or a documented disease that can be transmitted through urine or stool.
- For all ages, prior authorization is required over the limit requests: diapers (240 per month), wipes (2 boxes per month), and under pads (120 per month).
Next steps for providers: Providers should share this prior authorization guidance with their staff.
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
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