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

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TE, PDN, LVN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TE, U6, PDN, SPECIALIZED LVN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TE, UA, PDN, RN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TE, UA, U6, PDN, SPECIALIZED RN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TD, PDN, INDEPENDENTLY ENROLLED LVN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TD, U6, PDN, INDEPENDENTLY ENROLLED SPECIALIZED LVN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TD, UA, PDN, INDEPENDENTLY ENROLLED RN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
TD, UA, U6, PDN, INDEPENDENTLY ENROLLED SPECIALIZED RN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U3, TE, PDN, LVN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

T1000


AUTHORIZATION REQUIRED

 PR PRIVATE DUTY/INDEPENDENT NSG STAR KIDS, STAR, CHIP CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U3, TE, U6, PDN, SPECIALIZED LVN TMPPM, HTTP://WWW.TMHP.COM/PAGES/MEDICAID/MEDICAID_PUBLICATIONS_PROVIDER_MANUAL.ASPX,
MD GUIDELINE 1: PDN-SNV-PPECC-GUIDELINES.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY 10/1/2019
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