Inpatient and Observation Ambulance Services Autism Services Behavioral Health Services Case Management of Children and Pregnant Women (CPW) Chiropractic Services Dental Services Dermatology Services DME and Medical Supplies ENT Services Gastroenterology Services General OP Surgery Services Genetic Testing Services Hematology and Oncology Services Home Health Services Laboratory Services LTSS Services Neurology Services OB/GYN Services Office Visits and Consults Ophthalmology/Vision Oral Surgery Orthopedic Services Other Services Pain Management Services PCS - Personal Care Services PDN - Private Duty Nursing Services Pharmacy - Clinician Administered Drugs Plastic Surgery Services Podiatry Services PPECC Services Pulmonology Services Radiology Services Sleep Studies Therapy (PT, OT, ST) Services Urology Services

OUT-OF-NETWORK PROVIDERS

An authorization is required for all services performed by a non-participating provider with the following exceptions:

Texas Health Step (aka EPSDT exams) Well-child Exams (99381-99385 or 99391-99395)
Family Planning Services for STAR or STAR Kids members
Primary care services in a Federally Qualified Health Center (FQHC)
Routine in-hospital deliveries
Outpatient mental health or substance services, except for Psychological Testing Services


Enter Code To Check:

FILTER CODE: 
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97151


AUTHORIZATION REQUIRED

 PR BEHAVIOR ID ASSESSMENT BY PHYS/QHP EA 15 MIN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: HO (LBA), HN (LABA), AND HM (BT) AS APPLICABLE. MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97153


AUTHORIZATION REQUIRED

 PR ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: HO (LBA), HN (LABA), AND HM (BT) AS APPLICABLE. MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97154


AUTHORIZATION REQUIRED

 PR GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: HO (LBA), HN (LABA), AND HM (BT) AS APPLICABLE. MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97155


AUTHORIZATION REQUIRED

 PR ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: HO (LBA), HN (LABA), AND HM (BT) AS APPLICABLE. MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97156


AUTHORIZATION REQUIRED

 PR FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: HO (LBA), HN (LABA), AND HM (BT) AS APPLICABLE. MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97158


AUTHORIZATION REQUIRED

 PR GRP ADAPT BHV PRTCL MODIFCAJ PHYS/QHP EA 15 MIN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: HO (LBA), HN (LABA), AND HM (BT) AS APPLICABLE. MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

99366


AUTHORIZATION REQUIRED

 PR TEAM CONFERENCE FACE-TO-FACE NONPHYSICIAN STAR, STAR KIDS CHIP, CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM CHILDREN SERVICES HANDBOOK VOLUME 2, SECTION 2.3, MEDICAID AUTISM SERVICES POLICY HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMHP AND TMPPM, 2/1/2022