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

22856


AUTHORIZATION REQUIRED

 PR TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV CHIP, STAR, STAR KIDS CHIP PERINATE 4/1/2022
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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

22858


AUTHORIZATION REQUIRED

 PR TOT DISC ARTHRP ANT APPR DISC 2ND LEVEL CERVICAL CHIP, STAR, STAR KIDS CHIP PERINATE 4/1/2022
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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

22861


AUTHORIZATION REQUIRED

 PR REVISION TOTAL DISC ARTHROPLASTY, CERVICAL, SINGLE CHIP, STAR, STAR KIDS CHIP PERINATE 4/1/2022
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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

22864


AUTHORIZATION REQUIRED

 PR REMOVE TOTAL DISC ARTHROPLASTY, CERVICAL, SINGLE CHIP, STAR, STAR KIDS CHIP PERINATE 4/1/2022
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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

27278


AUTHORIZATION REQUIRED

 ARTHRD SI JT PRQ W/PLMT IARTIC IMPLT WO TFXJ DEV CHIP, STAR, STAR KIDS CHIP PERINATE 2/1/2024
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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

27279


AUTHORIZATION REQUIRED

 ARTHRODESIS SI JOINT PERCUTANEOUS/MIN INVASIVE 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. 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

33276


AUTHORIZATION REQUIRED

 INSERTION OF PHRENIC NERVE STIMULATOR GENERATOR AND STIMULATING LEAD(S) CHIP, STAR, STAR KIDS CHIP PERINATE 3/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
DIAGNOSIS CODES: AUTH IS REQUIRED IF NOT ONE OF THESE DIAGNOSIS CODES: G12.20, G12.22, G12.23-G12.25, G12.29, G12.8, G12.9, G47.35, G82.50-G82.54, G83.89, J96.10-J96.12, J96.20-J91.22, R06.81, Z99.11, 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

33277


AUTHORIZATION REQUIRED

 INSERTION OF PHRENIC NERVE STIMULATOR SENSING LEAD CHIP, STAR, STAR KIDS CHIP PERINATE 3/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
DIAGNOSIS CODES: AUTH IS REQUIRED IF NOT ONE OF THESE DIAGNOSIS CODES: G12.20, G12.22, G12.23-G12.25, G12.29, G12.8, G12.9, G47.35, G82.50-G82.54, G83.89, J96.10-J96.12, J96.20-J91.22, R06.81, Z99.11, 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

33278


AUTHORIZATION REQUIRED

 REMOVAL OF PHRENIC NERVE STIMULATOR GENERATOR AND LEAD(S) CHIP, STAR, STAR KIDS CHIP PERINATE 3/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
DIAGNOSIS CODES: AUTH IS REQUIRED IF NOT ONE OF THESE DIAGNOSIS CODES: G12.20, G12.22, G12.23-G12.25, G12.29, G12.8, G12.9, G47.35, G82.50-G82.54, G83.89, J96.10-J96.12, J96.20-J91.22, R06.81, Z99.11, 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

33279


AUTHORIZATION REQUIRED

 REMOVAL OF PHRENIC NERVE STIMULATOR STIMULATION OR SENSING LEAD(S) CHIP, STAR, STAR KIDS CHIP PERINATE 3/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
DIAGNOSIS CODES: AUTH IS REQUIRED IF NOT ONE OF THESE DIAGNOSIS CODES: G12.20, G12.22, G12.23-G12.25, G12.29, G12.8, G12.9, G47.35, G82.50-G82.54, G83.89, J96.10-J96.12, J96.20-J91.22, R06.81, Z99.11, 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
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