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

G0162


AUTHORIZATION REQUIRED

 PR HHC RN E&M PLAN SVS, 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U1, PCS RN ASSESSMENT FOR DELEGATION OF PCS OR CFC TASKS USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0162


AUTHORIZATION REQUIRED

 PR HHC RN E&M PLAN SVS, 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U1, U6, PCS RN ASSESSMENT FOR DELEGATION OF PCS OR CFC TASKS USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0162


AUTHORIZATION REQUIRED

 PR HHC RN E&M PLAN SVS, 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U2, PCS RN ASSESSMENT FOR DELEGATION OF PCS OR CFC TASKS USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0162


AUTHORIZATION REQUIRED

 PR HHC RN E&M PLAN SVS, 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U2, U6, PCS RN ASSESSMENT FOR DELEGATION OF PCS OR CFC TASKS USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0495


AUTHORIZATION REQUIRED

 PR RN CARE TRAIN/EDU IN HH STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PCS RN ASSESSMENT FOR DELEGATION OF PCS OR CFC TASKS USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

G0495


AUTHORIZATION REQUIRED

 PR RN CARE TRAIN/EDU IN HH STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U6, PCS RN ASSESSMENT FOR DELEGATION OF PCS OR CFC TASKS USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1019


AUTHORIZATION REQUIRED

 PR PERSONAL CARE SER PER 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
UD, U1, CFC PCS ATTENDANT CARE, ONLY-AGENCY MODEL USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1019


AUTHORIZATION REQUIRED

 PR PERSONAL CARE SER PER 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
UD, U1, U6, CFC PCS ATTENDANT CARE ONLY-SERVICE, RESPONSIBILITY OPTION MODEL USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1019


AUTHORIZATION REQUIRED

 PR PERSONAL CARE SER PER 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
UD, U2, CFC PCS ATTENDANT CARE ONLY-CONSUMER DIRECTED SERVICES MODEL USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1019


AUTHORIZATION REQUIRED

 PR PERSONAL CARE SER PER 15 MIN STAR KIDS CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
UD, U2, U6, CFC PCS ATTENDANT CARE, ONLY-AGENCY MODEL USE OF PCS AND CFC 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. AND TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PCS-Guidelines.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 5/31/2024
Page 1 of 3 (24 items)Prev123Next