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

20550


AUTHORIZATION REQUIRED

 PR INJECT TENDON SHEATH/LIGAMENT CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT AN ORTHOPAEDICS, ORTHOPAEDIC SURGERY, PEDIATRIC ORTHOPAEDIC SURGERY, 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

23000


AUTHORIZATION REQUIRED

 PR REMOVAL SUBDELTOID CALCAREOUS DEP,OPEN CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23020


AUTHORIZATION REQUIRED

 PR RELEASE SHLDR JOINT CONTRACTURE CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23030


AUTHORIZATION REQUIRED

 PR INCIS/DRAIN SHLDR ABSC/HEMA,DEEP CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23031


AUTHORIZATION REQUIRED

 PR DRAIN INFECT SHOULDER BURSA CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23040


AUTHORIZATION REQUIRED

 PR DEEP INCIS SHLDR BONE CORTEX CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23044


AUTHORIZATION REQUIRED

 PR EXPLOR/REMV INFECT GLENO-HUM JT CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23071


AUTHORIZATION REQUIRED

 PR EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3 CM/> CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23073


AUTHORIZATION REQUIRED

 PR EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5 CM/> CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

23075


AUTHORIZATION REQUIRED

 PR BIOPSY SHLDR SOFT TISSUES,DEEP CHIP, STAR, STAR KIDS CHIP PERINATE 6/1/2022
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, 6/6/2023
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