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:

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

G0156


AUTHORIZATION REQUIRED

 PR HHCP-SVS OF AIDE,EA 15 MIN CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0162


AUTHORIZATION REQUIRED

 PR HHC RN E&M PLAN SVS, 15 MIN CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0299


AUTHORIZATION REQUIRED

 PR HHS/HOSPICE OF RN EA 15 MIN CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0300


AUTHORIZATION REQUIRED

 PR HHS/HOSPICE OF LPN EA 15 MIN CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S9123


AUTHORIZATION REQUIRED

 PR NURSING CARE IN HOME RN CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S9124


AUTHORIZATION REQUIRED

 PR NURSING CARE, IN THE HOME; B CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S9140


AUTHORIZATION REQUIRED

 PR DIABETIC MANAGEMENT PROGRAM, CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S9208


AUTHORIZATION REQUIRED

 PR HOME MGMT PRETERM LABOR CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S9209


AUTHORIZATION REQUIRED

 PR HOME MGMT PPROM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S9211


AUTHORIZATION REQUIRED

 PR HOME MGMT GEST HYPERTENSION CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
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 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
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