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

T1025


AUTHORIZATION REQUIRED

 PR PED COMPR CARE PKG, PER DIEM STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PRESCRIBED PEDIATRIC EXTENDED CARE, GREATER THAN 4 HOURS USE OF PPECC 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 DHP PDN GUIDELINES. AND 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

T1025


AUTHORIZATION REQUIRED

 PR PED COMPR CARE PKG, PER DIEM STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U6, PRESCRIBED PEDIATRIC EXTENDED CARE, UP TO 4 HOURS USE OF PPECC 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 DHP PDN GUIDELINES. AND 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

T1026


AUTHORIZATION REQUIRED

 PR PED COMPR CARE PKG, PER HOUR STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
NON-EMERGENCY TRANSPORTATION USE OF PPECC 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 DHP PDN GUIDELINES. AND 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

T1026


AUTHORIZATION REQUIRED

 PR PED COMPR CARE PKG, PER HOUR STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U6, PRESCRIBED PEDIATRIC EXTENDED CARE, GREATER THAN 4 HOURS USE OF PPECC 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 DHP PDN GUIDELINES. AND 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

T2002


AUTHORIZATION REQUIRED

 PR N-ET; PER DIEM STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PRESCRIBED PEDIATRIC EXTENDED CARE, UP TO 4 HOURS USE OF PPECC 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 DHP PDN GUIDELINES. AND 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

T2002


AUTHORIZATION REQUIRED

 PR N-ET; PER DIEM STAR KIDS STAR, CHIP, CHIP PERINATE 12/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
U6, NON-EMERGENCY TRANSPORTATION USE OF PPECC 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 DHP PDN GUIDELINES. AND 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