Pharmacy

Provider Alert!
26Jul

Provider Alert! Collaborative Care Model (CoCM) Attestation Process to Update August 1, 2024

Date: July 26, 2024 Attention: All Providers Effective Date: August 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective August 1, 2024, the Attestation Form for the Collaborative Care Model (CoCM) in Texas Medicaid will be removed from the Texas Medicaid & Healthcare Partnership (TMHP) website and made available in the Provider Enrollment and Management System (PEMS). Prior to delivering CoCM services, applicable providers will be required to complete the CoCM attestation form in PEMS to...

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Provider Alert!
25Jul

Provider Alert! Updated Prior Authorization Criteria for Therapy with Burosumab-Twza (Crysvita)

Date: July 25, 2024 Attention: All Providers Effective date: July 1, 2024 Call to action: Texas Children’s Health Plan’s prior authorization (PA) criteria for renewal or continuation therapy with burosumab-twza (Crysvita) has changed, effective for dates of service on or after July 1, 2024. TCHP’s criteria for determining medical necessity for renewal or continuation therapy with burosumab-twza (Crysvita) is aligned with Texas Medicaid policy, as outlined in Texas Medicaid Provider Procedures Manual including the following update: Clinical documentation from the physician must confirm that the...

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Provider Alert!
25Jul

Provider Alert! Updated Prior Authorization Criteria for Elevidys

Date: July 24, 2024 Attention: All Providers Effective Date: September 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that Texas Health and Human Services Commission (HHSC) updated the prior authorization criteria for Elevidys (procedure code J1413), a benefit of Medicaid and CHIP, as the result of a recent review by the FDA. The update is effective September 1, 2024, for fee-for-service Medicaid clients. Elevidys (delandistrogene moxeparvovec-rokl) is an adeno-associated virus vector-based gene therapy indicated for the treatment of...

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Provider Alert!
24Jul

Provider Alert! Update to Recertification or Extension Prior Authorization Requests for Nusinersen (Spinraza)

Date: July 23, 2024 Attention: All Providers Effective date: July 1, 2024 Call to action: The purpose of this communication is to inform providers that effective for dates of service on or after July 1, 2024, recertification and extension prior authorization requests for nusinersen (Spinraza) will be subject to medical director review for additional 12-month periods. How this impacts providers: Providers should reference the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.10.1.2 “Recertification/Extension Requests (for all Antisense Oligonucleotides),” for additional recertification...

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Provider Alert!
23Jul

Provider Alert! Durable Medical Equipment Requests Exceeding Benefit Limitations

Date: July 23, 2024 Attention: All Providers Effective date: September 23, 2024 Call to action: Beginning September 23, 2024, Texas Children’s Health Plan (TCHP) guidelines and prior authorization requirements for Durable Medical Equipment (DME) and medical supplies will change. This change will align TCHP’s guidelines and prior authorization requirements with Texas Medicaid covered services and benefit limitations as outlined in the Texas Medicaid Provider Procedures Manual (TMPPM). Starting September 23, 2024, prior authorization requirements for DME and medical supplies are as follows: DME and medical supplies...

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Provider Alert!
12Jul

Provider Alert! Update to Smallpox and Mpox Vaccine Reimbursement for Texas Medicaid

Date: July 12, 2024 Attention: All Providers Effective Date: August 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that for dates of service on or after May 1, 2024, the smallpox and mpox vaccine (procedure code 90611) may be reimbursed for the following provider types and places of service for clients who are 18 years of age or older: Place of ServiceProvider TypeOfficePhysicians, physician assistants, nurse practitioners, clinical nurse specialistsOutpatient hospitalHospital providers Effective August 1, 2024, for dates...

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Provider Alert!
12Jul

Provider Alert! Important Information on Checks Sent by Change Healthcare

Date: July 12, 2024 Attention: All Providers Texas Children’s Health Plan (TCHP) has just been notified that due to a process failure at Change Health Care (Change) a number of invalid checks have been erroneously issued. Change previously served as our payment processor. We transitioned our payment processing in February of this year in response to the cyber-security incident that caused Change to suspend services. These paper checks were erroneously issued to a number of our providers for amounts previously paid via check...

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Provider Alert!
11Jul

Provider Alert! Hurricane Beryl Guidance from the Texas State Board of Pharmacy

Date: July 11, 2024 Attention: Pharmacy providers Background: On Monday, July 8, Hurricane Beryl made landfall on the Texas coast, causing significant damage and flooding across numerous counties. This situation has forced many residents to evacuate to temporary locations. Call to action: In response to this emergency, the Texas State Board of Pharmacy has issued important guidance regarding emergency procedures. Pharmacists in Texas are authorized to dispense up to a 30-day supply of medication (excluding Schedule II controlled substances) for individuals affected by...

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Provider Alert!
25Jun

Provider Alert! Texas Children’s Health Plan Announces Partnership with Cotiviti

Date: June 24, 2024 Attention: All Providers Effective Date: October 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that beginning October 1, 2024, we will partner with Cotiviti, Inc (Cotiviti) for periodic post payment reviews of paid medical claims. The post payment reviews to be conducted are: Retrospective Clinical Claim Validation (RCCV) DRG, observation, and readmission reviews. These are the same/similar reviews that are currently being conducted, just with a new vendor, Cotiviti. What providers can expect: CCV...

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Provider Alert!
21Jun

Provider Alert! Co-pays for CHIP COVID-19 services will resume starting October 1, 2024

Date: June 21, 2024 Attention: All Providers Effective Date: October 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that beginning October 1, 2024, providers may begin collecting Children’s Health Insurance Program (CHIP) co-pays for COVID-19 related services. As you know, during the COVID-19 public health emergency, the Texas Health and Human Services Commission (HHSC) waived co-pays for COVID-19 vaccines, testing, and treatment for CHIP members. This waiver will end on September 30, 2024. Important reminders regarding co-payment for...

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