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

91113


AUTHORIZATION REQUIRED

 PR GI TRACT IMAGING INTRALUMINAL COLON I&R CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
DIAGNOSIS CODES: AUTH IS REQUIRED IF NOT ONE OF THESE DIAGNOSIS CODES: K63.5, K92.1, K92.2, R19.5, Z53.09, Z53.8, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

A9268


AUTHORIZATION REQUIRED

 PROGRAMMER FOR TRANSIENT, ORALLY INGESTED CAPSULE STAR, STAR KIDS, CHIP, CHIP PERINATE 1/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THESE PROCEDURE CODES ARE NOT COVERED SERVICES BUT DHP WILL REVIEW REQUESTS FOR THESE PROCEDURE CODES ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

A9269


AUTHORIZATION REQUIRED

 PROGRAMABLE, TRANSIENT, ORALLY INGESTED CAPSULE, FOR USE WITH EXTERNAL PROGRAMMER, PER MONTH STAR, STAR KIDS, CHIP, CHIP PERINATE 1/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THESE PROCEDURE CODES ARE NOT COVERED SERVICES BUT DHP WILL REVIEW REQUESTS FOR THESE PROCEDURE CODES ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM