Prior Authorizations – The Checkup

24AprApril 24, 2019

Prior Authorization Reference Information

The Texas Children’s Health Plan website now has an additional resource for information related to prior authorization requirements. The Prior Authorization Reference Information documents the codes that require authorization for payment based on authorization category. This list is not yet all-inclusive. It can be found at: https://www.texaschildrenshealthplan.org/sites/default/files/pdf/PA%20Code%20List%20December%202018.pdf In addition, providers can submit an authorization request online for the codes listed on the Prior Authorization Reference Information document via Clear Coverage. For access to or training on the use of Clear Coverage,...

By Texas Children's Health PlanOB/GYNs, Office Managers, Primary Care Providers, Provider Alert, SpecialistsClear Coverage, Prior Authorization, Prior Authorizations0 CommentsRead more...

17MayMay 17, 2017

No Prior Authorizations Required for Texas Children’s Health Plan (TCHP) In-Network Observations

1. In-network Observation stays do not require prior-authorization. 2. Hospital stays that include less than two bed days (less than “two midnights”) at the time of submission will be categorized as Observation Level of Care with some exceptions: a. Obstetrical deliveries b. Patient deaths c. Against Medical Advice (AMA) discharges d. Intensive Care Unit (ICU) admissions e. Pediatric Intensive Care Unit (PICU) admissions f. Pediatric Progressive Care Unit (PCU) g. Initial Neonatal Intensive Care Unit (NICU) admissions h. Neonatal Intensive Care Unit (NICU) readmissions within 28 days i. Behavioral Health...

By Texas Children's Health PlanFacilitiesAdmissions, In-Network, Prior Authorizations, Utilization Management0 CommentsRead more...

01MayMay 1, 2017

Need Help Navigating Pharmacy Prior Authorizations?

Pharmacy Prior Authorizations (PAs) can be a difficult administrative burden for providers and staff, however, they help ensure patients are receiving the most evidence-based, cost-effective medications. The Vendor Drug Program (VDP) is the state resource for the Texas Medicaid formulary and Preferred Drug List (PDL). VDP has provided a very helpful guide to managing pharmacy benefits for your patients. You can access this resource here: http://casestudies.txhealthsteps.com/stepsQuickCourses/prescribers/ This Quick Course reviews the following: Searching Formulary for prescription and OTC drugs Checking the Preferred Drug List...

By Texas Children's Health PlanFacilities, OB/GYNs, Office Managers, Primary Care Providers, SpecialistsPAs, PDL, Pharmacy, Preferred Drug List, Prior Authorizations, Texas Medicaid Formulary, Texas Vendor Drug Program, VDP0 CommentsRead more...

15FebFebruary 15, 2016

Prevent Behavioral Health Readmissions

Prevent Behavioral Health Readmissions Poor access to prescribed medications after discharge is one of the most common reasons for behavioral health readmissions. One effective way to help ensure access to medications post-discharge is to obtain and verify prior authorization for the medications before discharge. Texas Children’s Health Plan follows the state of Texas Medicaid Guidelines for the use and approval of antipsychotics in children. Criteria for approval can be accessed here. If a patient does not meet criteria and the prior authorization...

By Texas Children's Health PlanPrimary Care Providersappeal, Behavioral Health, Prescribed Medicine, Prescriptions, Prior Authorizations, Readmissions0 CommentsRead more...

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