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

H2023


AUTHORIZATION REQUIRED

 PR SUPPORTED EMPLOY, PER 15 MIN STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U1, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, SUPPORTED EMPLOYMENT, AGENCY MODEL USE OF LTSS IS IDENTIFIED DURING THE STAR KIDS - SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

H2023


AUTHORIZATION REQUIRED

 PR SUPPORTED EMPLOY, PER 15 MIN STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U2, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, SUPPORTED EMPLOYMENT, SERVICE RESPONSIBILITY OPTION USE OF LTSS IS IDENTIFIED DURING THE STAR KIDS - SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

H2023


AUTHORIZATION REQUIRED

 PR SUPPORTED EMPLOY, PER 15 MIN STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
UC, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, SUPPORTED EMPLOYMENT, CDS OPTION USE OF LTSS IS IDENTIFIED DURING THE STAR KIDS - SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

H2025


AUTHORIZATION REQUIRED

 PR SUPP MAINT EMPLOY, 15 MIN STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U1, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, EMPLOYMENT ASSISTANCE, AGENCY MODEL USE OF LTSS IS IDENTIFIED DURING THE STAR KIDS - SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

H2025


AUTHORIZATION REQUIRED

 PR SUPP MAINT EMPLOY, 15 MIN STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U2, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, EMPLOYMENT ASSISTANCE, SERVICE RESPONSIBILITY OPTION USE OF LTSS IS IDENTIFIED DURING THE STAR KIDS - SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

H2025


AUTHORIZATION REQUIRED

 PR SUPP MAINT EMPLOY, 15 MIN STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
UC, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, EMPLOYMENT ASSISTANCE, CDS OPTION USE OF LTSS IS IDENTIFIED DURING THE STAR KIDS - SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S5101


AUTHORIZATION REQUIRED

 PR ADULT DAY CARE PER HALF DAY STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, DAY ACTIVITIES AND HEALTH SERVICES USE OF DAHS IS IDENTIFIED DURING THE STAR KIDS SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S5101


AUTHORIZATION REQUIRED

 PR ADULT DAY CARE PER HALF DAY STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U6, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, DAY ACTIVITIES AND HEALTH SERVICES USE OF DAHS IS IDENTIFIED DURING THE STAR KIDS SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S5101


AUTHORIZATION REQUIRED

 PR ADULT DAY CARE PER HALF DAY STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, DAY ACTIVITIES AND HEALTH SERVICES USE OF DAHS IS IDENTIFIED DURING THE STAR KIDS SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

S5101


AUTHORIZATION REQUIRED

 PR ADULT DAY CARE PER HALF DAY STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U6, EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR, DAY ACTIVITIES AND HEALTH SERVICES USE OF DAHS IS IDENTIFIED DURING THE STAR KIDS SCREENING AND ASSESSMENT INSTRUMENT. AS SUCH, THE NEED FOR THE BENEFIT IS DETERMINED THROUGH THE NEEDS OF THE MEMBERS AND THE FAMILY RATHER THAN THROUGH GUIDELINES., HTTPS://HHS.TEXAS.GOV/LAWS-REGULATIONS/HANDBOOKS/SKH/STAR-KIDS-HANDBOOK CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 11/1/2016
Page 1 of 8 (73 items)Prev12345678Next