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

0604T


ENVOLVE

PR REMOTE OCT RETINA 1ST DEV SET-UP & PT EDUCAJ CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0605T


ENVOLVE

PR REM OCT RETINA TECHL SUPRT MIN 8 DLY REC EA 30D CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0606T


ENVOLVE

PR REMOTE OCT RETINA REVIEW I&R PHYS/QHP EA 30 D CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0616T


ENVOLVE

PR INSJ IRIS PROSTH W/SUTURE FIXATION&RPR/RMVL IRIS CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0617T


ENVOLVE

PR INSJ IRIS PROSTH RMVL CRYSTLN LENS &INSJ IO LENS CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0618T


ENVOLVE

PR INSJ IRIS PROSTH SECONDARY IO LENS PLMT/EXCHANGE CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0621T


ENVOLVE

PR TRABECULOSTOMY AB INTERNO BY LASER CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

0622T


ENVOLVE

PR TRABECULOSTOMY AB INTERNO LASER W/OPH ENDOSCOPE CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11440


ENVOLVE

PR EXC SKIN BENIG <5MM FACE,FACIAL CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11441


ENVOLVE

PR EXC SKIN BENIG 0.6-1CM FACE,FACIAL CHIP, STAR, STAR KIDS CHIP PERINATE 11/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: OPHTHALMOLOGY, ROUTINE VISION AND MEDICAL EYE CARE SERVICES FOR DRISCOLL HEALTH PLAN ARE ADMINISTERED BY ENVOLVE VISION OF TEXAS. ALL OPHTHALMOLOGY SERVICES REQUESTS SHOULD BE SUBMITTED TO ENVOLVE VISION OF TEXAS AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX OR VIA FAX AT 1-877-865-1077. IT IS THE PROVIDER'S RESPONSIBILITY TO VERIFY AUTHORIZATION REQUIREMENTS THROUGH ENVOLVE VISION OF TEXAS. PLAN SPECIFICS OUTLINING BENEFIT INFORMATION FOR DHP MEMBERS ARE LOCATED THROUGH THE ENVOLVE VISION OF TEXAS 24/7 PROVIDER PORTAL AT HTTPS://VISIONBENEFITS.ENVOLVEHEALTH.COM/LOGON.ASPX. ENVOLVE VISION OF TEXAS PROVIDER SERVICES CAN BE REACHED AT 1-800-531-2818. CLAIMS FOR ROUTINE AND MEDICAL EYE CARE SERVICES PERFORMED MUST BE SUBMITTED TO ENVOLVE VISION OF TEXAS. CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY
Page 1 of 45 (450 items)Prev1234567…434445Next