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


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

81105


AUTHORIZATION REQUIRED

 CHG HPA-1 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81106


AUTHORIZATION REQUIRED

 CHG HPA-2 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81107


AUTHORIZATION REQUIRED

 CHG HPA-3 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81108


AUTHORIZATION REQUIRED

 CHG HPA-4 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81109


AUTHORIZATION REQUIRED

 CHG HPA-5 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81110


AUTHORIZATION REQUIRED

 CHG HPA-6 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81111


AUTHORIZATION REQUIRED

 CHG HPA-9 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81112


AUTHORIZATION REQUIRED

 CHG HPA-15 GENOTYPING GENE ANALYSIS COMMON VARIANT CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81120


AUTHORIZATION REQUIRED

 CHG IDH1 COMMON VARIANTS CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

81121


AUTHORIZATION REQUIRED

 CHG IDH2 COMMON VARIANTS CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: GENETIC-TESTING-FOR-SUSPECTED-DISABILITY.PDF,
MD GUIDELINE 2: USING-LARGE-GENETIC-TESTING-PANELS.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 10/10/2023
Page 1 of 33 (330 items)Prev1234567…313233Next