Provider Alert! Prior authorization Updates   

Date: July 23, 2021

Attention: All Providers

Effective Dates: August 1, 2021 and November 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: Services no longer requiring a prior authorization effective August 1, 2021 include the following:

• Biofeedback Codes 90901, 90912, and 90913
• Durable Medical Equipment (DME) repair over 35 units

Services requiring a prior authorization for dates of service on or after August 1, 2021 include the following:

• Mobility Aides Code E1035 Transfer system
• Breast reduction Code 19318
• Vein procedure Code 36473

Services requiring a prior authorization for dates of service on or after November 1, 2021 include the following:

• Durable Medical Equipment (DME) when billed amount exceeds $500- Miscellaneous Code T199
• Prosthetics Code L8610 Ocular Implant
• Cerebral Seizure Monitoring – Inpatient EEG for Codes:

o 95726
o 95700
o 95718
o 95720
o 95722
o 95724

• Clinician Administered Drug Code Q2026 Dermal filler
• Functional Endoscopic Sinus Surgery inpatient/outpatient for Codes:

o 31240
o 31253
o 31254
o 31255
o 31256
o 31257
o 31259
o 31267
o 31276
o 31287
o 31288

• Gait Trainer/Standers for Code E0641
• Joint Replacement inpatient/outpatient for Codes:

o 23470
o 23472
o 23473
o 23474
o 24360
o 24361
o 24362
o 24363
o 24370
o 24371
o 27120
o 27122
o 27125
o 27130
o 27132
o 27134
o 27137
o 27138
o 27412
o 27446
o 27447
o 27486
o 27487
o 29866
o 29867
o 29868

• Spinal Surgery for Members age 21 and older, STAR only for Codes:

o 22100
o 22101
o 22102
o 22110
o 22112
o 22114
o 22206
o 22207
o 22210
o 22212
o 22214
o 22220
o 22224
o 22532
o 22533
o 22548
o 22551
o 22554
o 22556
o 22558
o 22586
o 22590
o 22600
o 22610
o 22630
o 22633
o 22800
o 22802
o 22804
o 22808
o 22810
o 22812
o 22818
o 22819
o 22830
o 22849
o 22850
o 22852
o 22855
o 22865
o 22899
o 63001
o 63003
o 63005
o 63011
o 63012
o 63015
o 63016
o 63017
o 63020
o 63030
o 63040
o 63042
o 63045
o 63046
o 63047
o 63050
o 63055
o 63056
o 63064
o 63075
o 63077
o 63081
o 63085
o 63087
o 63090
o 63101
o 63102
o 63170
o 63172
o 63173
o 63185
o 63190
o 63191
o 63194
o 63195
o 63196
o 63198
o 63199
o 63200
o 63250
o 63251
o 63252
o 63265
o 63267
o 63268
o 63300
o 63301
o 63302
o 63303
o 63304
o 63305
o 63306
o 63307
o 63308

Next steps for providers: Providers should share these prior authorization requirements with their staff.

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.