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:

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

94610


AUTHORIZATION REQUIRED

 PR INTRAPULMONARY SURFACTANT ADMINISTJ PHYS/QHP CHIP, STAR, STAR KIDS, CHIP PERINATE 8/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

94625


AUTHORIZATION REQUIRED

 PR PHYS/QHP SVCS OP PULM REHAB WO CONT OXIMTRY MNTR CHIP, STAR, STAR KIDS, CHIP PERINATE 8/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

94626


AUTHORIZATION REQUIRED

 PR PHYS/QHP SVCS OP PULM REHAB W/CONT OXIMTRY MNTR CHIP, STAR, STAR KIDS, CHIP PERINATE 8/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

94664


AUTHORIZATION REQUIRED

 PR DEMO &/OR EVAL,PT USE,AEROSOL DEVICE CHIP, STAR, STAR KIDS, CHIP PERINATE 8/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

94669


AUTHORIZATION REQUIRED

 PR MECHANICAL CHEST WALL OSCILLATION LUNG FUNCTION CHIP, STAR, STAR KIDS, CHIP PERINATE 8/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

94772


AUTHORIZATION REQUIRED

 BREATH RECORDING, INFANT CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

C7556


AUTHORIZATION REQUIRED

 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH BRONCHIAL ALVEOLAR LAVAGE AND TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC CHIP, STAR, STAR KIDS, CHIP PERINATE 8/1/2024
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF 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