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

11042


AUTHORIZATION REQUIRED

 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,=<20 SQ CM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11043


AUTHORIZATION REQUIRED

 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,=<20 SQ CM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11044


AUTHORIZATION REQUIRED

 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,=<20 SQ CM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11045


AUTHORIZATION REQUIRED

 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,EACH ADD 20 SQ CM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11046


AUTHORIZATION REQUIRED

 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,EACH ADD 20 SQ CM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11047


AUTHORIZATION REQUIRED

 PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,EACH ADD 20 SQ CM CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11055


AUTHORIZATION REQUIRED

 PR TRIM HYPERKERATOTIC SKIN LESION, ONE CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11056


AUTHORIZATION REQUIRED

 TRIM BENIGN HYPERKERATOTIC SKIN LESION,2-4 CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11057


AUTHORIZATION REQUIRED

 TRIM BENIGN HYPERKERATOTIC SKIN LESION,>4 CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

11719


AUTHORIZATION REQUIRED

 PR TRIM NAIL(S) CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT A PODIATRIST, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/24/2024
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