Tag - Prior Authorization

Provider Alert!

Provider Alert! Coverage of Elevidys Begins January 2024

Date: February 27, 2024 Attention: All Providers Prior authorization effective date: February 1, 2024 Call to action: The purpose of this communication is to inform providers that on January 1, 2024, Elevidys became a benefit of Medicaid and CHIP. Texas Health and Human Services Commission (HHSC) requires prior authorization for Elevidys (procedure code J1413) for Medicaid and CHIP, effective February 1, 2024. Elevidys is an adeno-associated virus vector-based gene therapy indicated for the treatment of ambulatory pediatric clients ages 4 through 5 years with...

Provider Alert!

Provider Alert! HCPCS and CPT Code Prior authorization Update

Date: February 26, 2024 Attention: All Providers Effective date: January 1, 2024 Call to action: The purpose of this communication is to offer information about the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) prior authorization updates. Resource: https://www.tmhp.com/sites/default/files/file-library/resources/rate-and-code-updates/hcpcs-updates/2024-hcpcs-special-bulletin.pdf How this impacts providers: Effective January 1, 2024 Texas Children’s Health Plan’s (TCHP's) prior authorization updates are listed below. These changes follow guidance from Texas Medicaid and Healthcare Partnership (TMHP). Medical necessity criteria for utilization review will be in accordance with Texas Medicaid...

Provider Alert!

Provider Alert! Enzyme Replacement Therapy Prior Authorization Update

Date: February 26, 2024 Attention: All Providers Effective date: February 1, 2024 Call to action: Texas Children’s Health Plan would like to make providers aware of prior authorization updates for certain enzyme replacement therapies. In alignment with Texas Medicaid Provider Procedure Manual (TMPPM) requirements, effective for dates of service on or after February 1, 2024, prior authorization will be required for enzyme replacement therapy velmanse alfa-tycv (Lamzede), procedure code J0217, and pegunigalsidase alfa-iwxj (Elfabrio), procedure code J2508. Prior Authorization Requirements include the following: Velmanse alfa-tycv...

Provider Alert!

Provider Alert! Reminder: Prior Authorization Form Completion

Date: February 13, 2024 Attention: All Providers Call to action: Texas Children’s Health Plan (TCHP) supports the guidance from Texas Health and Human Services Commission (HHSC) on rejecting the Prior Authorization (PA) received with incomplete or insufficient documentation per Uniform Managed Care Manual (UMCM), Chapter 3.22. ‘Essential Information’ is the information required to initiate the PA review process, and are as follows: Member name Member number or Medicaid number Member date of birth Requesting provider name Requesting provider’s National Provider Identifier (NPI) Service requested – Current Procedural Terminology (CPT),...

Provider Alert!

Provider Alert! Updated Prior Authorization Information for Benlysta (procedure code J0490) and Saphnelo (procedure code J0491)

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of prior authorization updates for Belimumab (Benlysta), procedure code J0490, and Anifrolumab-fnia (Saphnelo), procedure code J0491. Effective March 1, 2022, there is no prior authorization requirement for both, and age and diagnosis restrictions are indicated below. Benlysta (J0490) is indicated to treat the following:  Active, autoantibody-positive, systemic lupus erythematosus (SLE) in clients who are 5 years of age or older, and receiving standard therapy Adult clients with active Lupus Nephritis...

Provider Alert!

Provider Alert! Coverage of Vyjuvek (procedure code J3401) Begins January 2024; Prior Authorization Effective February 2024

Date: December 6, 2023 Attention: All Providers Prior Authorization Effective Date: February 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that on January 1, 2024, Vyjuvek will become a benefit of Medicaid and CHIP. Texas Health and Human Services Commission (HHSC) will require prior authorization for Vyjuvek (procedure code J3401) for Medicaid and CHIP, effective February 1, 2024. Vyjuvek is the first U.S. Food and Drug Administration (FDA) approved topical gene therapy that delivers new COL7A1 genes...

Provider Alert!

Provider Alert! Coverage of Roctavian (procedure code J1412) Begins January 2024; Prior Authorization Effective February 2024

Date: December 6, 2023 Attention: All Providers Prior Authorization Effective Date: February 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that on January 1, 2024, Roctavian will become a benefit of Medicaid and CHIP. Texas Health and Human Services Commission (HHSC) will require prior authorization for Roctavian (procedure code J1412) for Medicaid and CHIP, effective February 1, 2024. Roctavian (valoctocogene roxaparvovec-rvox) is an adeno-associated virus vector-based gene therapy indicated to treat adult clients with severe hemophilia A...

Provider Alert!

Provider Alert! Coverage of Adstiladrin (procedure code J9029) Begins January 2024; Prior Authorization Effective February 2024

Date: December 6, 2023 Attention: All Providers Prior Authorization Effective Date: February 1, 2024 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective February 1, 2024, Texas Health and Human Services (HHSC) will be implementing prior authorization criteria for Adstiladrin (procedure code J9029). Adstiladrin (nadofaragene firadenovec-vncg) is an adenoviral vector-based gene therapy indicated to treat adult clients with high-risk Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS) with or without papillary...

Provider Alert!

Provider Alert! Prior Authorization Signature Requirements

Date: November 20, 2023 Attention: All Providers Effective Date: December 20, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to remind providers that per Texas Medicaid Provider Procedures Manual (TMPPM) Section 5.1, only wet or electronic signatures are accepted for prior authorizations. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures. Stamped signatures, typed fonts, and images of wet signatures are not accepted. How this impacts...

Provider Alert!

Provider Alert! Texas Children’s® Link: Efficiently Submit Prior Authorizations

Date: November 6, 2023 Attention: All Providers Call to action: Texas Children’s Health Plan (TCHP) would like to remind providers that they can submit prior authorizations securely online via Texas Children's® Link, our online provider portal. Providers are encouraged to submit authorization requests on our portal since this is the most efficient way for our team to process authorizations. To access Texas Children's® Link, click here. Important benefits of using the new portal to submit authorizations include: Real time access to authorization status information –...