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

36460


AUTHORIZATION REQUIRED

 PR TRANSFUSION FETAL,INTRAUTER CHIP, STAR, STAR KIDS, CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH REQUIRED IF REFERRED TO PROVIDER IS A NOT A MATERNAL-FETAL MEDICINE (MFM), EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

57558


AUTHORIZATION REQUIRED

 PR D&C OF CERVIX STUMP 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: O01.9, O00.1-O00.2, O00.8-O00.9, O02.0, O02.1, O03.0, O03.1, O03.2, O03.30-O03.31, O03.33-O03.34, O03.37-O03.39, O03.4, O03.5, O03.6, O03.7, O03.80-O03.88, O03.9, O04.5, O04.6, O04.7, O04.80-O04.89, O07.0, O07.1, O07.2, O07.30-O07.39, O07.4, O20.0, O20.8-O20.9, O43.211-O43.213, O43.221-O43.223, O43.231-O43.233, O43.239, O44.00-O44.03, O44.10-O44.13, O45.001-O45.003, O45.011-O45.013, O45.021-O45.023, O45.091-O45.093, O45.8X1-O45.9-8X3, O45.8X9, O45.91-O45.93, O46.001-O46.003, O46.011-O46.013, O46.021-O46.023, O46.091-O46.093, O46.009, O46.029. O46.099, O46.19, O46.8X1-O46.8X3, O46.8X19, O46.91-O46.93, O67.0, O67.8-O67.9, O72.0, O72.1, O72.2, O72.3, O73.0, O73.1, Z33.2, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58150


AUTHORIZATION REQUIRED

 PR TOTAL ABDOM HYSTERECTOMY 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58152


AUTHORIZATION REQUIRED

 PR TOTAL ABD HYSTERECTOMY+BLAD REPR 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58180


AUTHORIZATION REQUIRED

 PR SUPRACERV ABD HYSTERECTOMY 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58200


AUTHORIZATION REQUIRED

 PR TOTAL ABD HYSTEREC+LTD NODES 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58210


AUTHORIZATION REQUIRED

 PR RADICAL ABD HYSTEREC+PELV NODES 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58240


AUTHORIZATION REQUIRED

 PR PELVIC EXENTERATN,GYN MALIGNANCY 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58260


AUTHORIZATION REQUIRED

 PR VAGINAL HYSTERECTOMY,UTERUS 250 GMS/< 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

58262


AUTHORIZATION REQUIRED

 PR VAG HYST,RMV TUBE/OVARY 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, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
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