Tag - Utilization Management

Provider Alert!
29Nov

Provider Alert! Reminder: Discharge Authorizations Fax Line

Date: November 29, 2023 Attention: All Providers Call to action: Texas Children’s Health Plan (TCHP) would like to remind providers that the Discharge Authorizations Fax Line is now live. The toll-free number is 866-839-9879. Providers should use this line to send in authorization requests for members who are hospitalized at the time of the request and services or equipment that are necessary for care of the member immediately after discharge. Requests unrelated to discharge needs should not be sent to this number. Discharge Authorizations...

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Provider Alert!
19Apr

Provider Alert! Retracted: Coordination of Benefits for Utilization Management Update

Date: April 19, 2023 Attention: All Providers Call to action:  As you may remember, Texas Children’s Health Plan (TCHP) previously communicated changes to our Coordination of Benefits Procedure on February 15, 2023. After careful consideration and listening to your concerns, the Utilization Management (UM) team has decided to pause on any changes and revert back to the original procedure. A link to the former procedure that is currently being followed is available here. How this impacts providers: Providers that received a rejection letter due...

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03Oct

Provider Alert! COVID-19 Disaster Declaration – ALERT #5 – Prior Authorization Adjustments

Date: October 3, 2022 Attention: All Providers Effective Date: September 26, 2022 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. The Prior Authorization Adjustments listed here are extended until October 31, 2022. This COVID-19 Disaster Declaration extension does NOT apply to 90-day authorizations. As of January 1, 2021, 90-day authorization...

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03Oct

Provider Alert! Guidance on Appeals and Fair Hearing Requests due to COVID-19

Date: October 3, 2022 Attention: All providers Effective Date: September 26, 2022 The content in this message will remain in effect through October 31, 2022 as announced by the Health and Human Services Commission (HHSC). TCHP COVID-19 Utilization Management Procedure and provider alerts can be found here: http://www.thecheckup.org/provider-alerts/ Providers should monitor the Texas Children’s Health Plan 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...

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Provider Alert!
25Jan

Provider Alert! Signature Requirement Reinstated on DME Forms

Date: January 19, 2022 Attention: DME Providers Effective Date: January 1, 2022 TCHP COVID-19 Utilization Management Procedure and TCHP provider alerts can be found here: http://www.thecheckup.org/provider-alerts/ TCHP network providers should monitor the 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: Effective January 1, 2022, a member or member’s authorized representative’s signature is required on DME Certification and...

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Provider Alert!
08Dec

Provider Alert! Annual Utilization Management Notice to All Providers

Attention: All Providers 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.  Affirmative Statement about Incentives As a reminder, Texas Children’s Health Plan (TCHP) Utilization Management (UM) decision-making is based on our Policies, Procedures, and Guidelines. They are based only on appropriateness of care and service and the existence...

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Provider Alert!
20May

Provider Alert! Reminder: Authorization Guidelines for a hospitalized member – post discharge services and supplies

Attention: All Providers Effective Date: May 20, 2020 Call to action: Texas Children’s Health Plan (TCHP) is aligned with the Uniform Managed Care Contract (UMCC) Guideline for members with an authorization request during hospitalization (reference: 8.1.8 Utilization Management). The guideline states that TCHP must issue coverage determinations for a member who is hospitalized at the time of the request, within one Business Day of receiving the request for services or equipment that will be necessary for the care of the Member immediately...

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17May

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...

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12Mar

Attention: Star Kids Providers: Prior Authorization required on all Vendor Drug Program (VDP) identified medications

Texas Children’s Health Plan requires prior authorization (PA) on all medications on the VDP website prior to dispensing to members. To obtain a list of medications requiring prior authorization, visit the VDP website at: http://www.txvendordrug.com/formulary/preferred-drugs.shtml Providers can also view instructions on accessing and using the formulary at the Texas Children’s Health Plan website: http://www.thecheckup.org/2016/06/09/do-you-know-how-to-access-the-texas-childrens-health-plan-formulary/ Providers can submit PA documentation to Texas Children’s Health Plan’s pharmacy benefit manager, Navitus. PA forms can be found here: https://www.navitus.com/texas-medicaid-star-chip/prior-authorization-forms.aspx Prior authorizations need to be submitted to Navitus by faxing to...

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31Oct

Provider Alert! All Texas Children’s Health Plan providers and facilities Utilization Management Guidelines effective November 1, 2016

Texas Children’s Health Plan has developed Utilization Management guidelines that serve as criteria for the determination of medical necessity for services that require prior authorization. These guidelines will be effective on November 1, 2016. The goal of Texas Children’s Health Plan’s Utilization Management guidelines is to encourage the highest quality care from the right provider in the right setting. Utilization Management guidelines are available for you to review. Please contact Texas Children’s Health Plan’s Provider Relations department at 832-828-1008 or toll-free at...

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