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

95782


AUTHORIZATION REQUIRED

 PR POLYSOM <6 YRS SLEEP STAGE 4/> ADDL PARAM ATTND CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Pediatric-Sleep-Study.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95783


AUTHORIZATION REQUIRED

 PR POLYSOM <6 YRS SLEEP W/CPAP/BILVL VENT 4/> PARAM CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Pediatric-Sleep-Study.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95800


AUTHORIZATION REQUIRED

 PR SLEEP STUDY, UNATTENDED, RECORD HEART RATE/O2 SAT/RESP ANAL/SLEEP TIME CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95801


AUTHORIZATION REQUIRED

 PR SLEEP STUDY, UNATTENDED, RECORD HEART RATE/O2 SAT/RESP ANALYSIS CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95803


AUTHORIZATION REQUIRED

 PR ACTIGRAPHY TESTING, 3-14 DAY CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95805


AUTHORIZATION REQUIRED

 PR MULTIPLE SLEEP LATENCY TEST CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95806


AUTHORIZATION REQUIRED

 PR SLEEP STUDY, UNATTENDED STAR, STAR KIDS, CHIP, CHIP PERINATE 1/6/2016
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. 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

95807


AUTHORIZATION REQUIRED

 PR SLEEP STUDY, ATTENDED CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95808


AUTHORIZATION REQUIRED

 PR POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Pediatric-Sleep-Study.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

95810


AUTHORIZATION REQUIRED

 PR POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND CHIP, STAR, STAR KIDS CHIP PERINATE 1/1/2023
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Pediatric-Sleep-Study.pdf		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
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