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:

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

36415


AUTHORIZATION REQUIRED

 PR COLLECTION VENOUS BLOOD,VENIPUNCTURE 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 CHILD ABUSE PEDIATRIC, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

46600


AUTHORIZATION REQUIRED

 PR ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD 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 CHILD ABUSE PEDIATRIC, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

57452


AUTHORIZATION REQUIRED

 PR COLPOSCOPY,CERVIX W/ADJ VAGINA 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 CHILD ABUSE PEDIATRIC, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90791


AUTHORIZATION REQUIRED

 PR PSYCHIATRIC DIAGNOSTIC EVALUATION CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF MORE THAN 1 SERVICE PER ROLLING YEAR., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90792


AUTHORIZATION REQUIRED

 PR PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF MORE THAN 1 SERVICE PER ROLLING YEAR., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90832


AUTHORIZATION REQUIRED

 PR PSYCHOTHERAPY W/PATIENT 30 MINUTES CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF OVER BENEFIT LIMITS; REFER TO TMPPM FOR ADDITIONAL INFORMATION AND BENEFIT LIMITS TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90833


AUTHORIZATION REQUIRED

 PR PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 30 MIN CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF OVER BENEFIT LIMITS; REFER TO TMPPM FOR ADDITIONAL INFORMATION AND BENEFIT LIMITS TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90834


AUTHORIZATION REQUIRED

 PR PSYCHOTHERAPY W/PATIENT 45 MINUTES CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF OVER BENEFIT LIMITS; REFER TO TMPPM FOR ADDITIONAL INFORMATION AND BENEFIT LIMITS TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90836


AUTHORIZATION REQUIRED

 PR PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 45 MIN CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF OVER BENEFIT LIMITS; REFER TO TMPPM FOR ADDITIONAL INFORMATION AND BENEFIT LIMITS TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

90837


AUTHORIZATION REQUIRED

 PR PSYCHOTHERAPY W/PATIENT 60 MINUTES CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2022
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
ALERT: AUTH REQUIRED IF OVER BENEFIT LIMITS; REFER TO TMPPM FOR ADDITIONAL INFORMATION AND BENEFIT LIMITS TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
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