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

92507


AUTHORIZATION REQUIRED

 PR SPEECH/HEARING THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92508


AUTHORIZATION REQUIRED

 PR SPEECH/HEARING THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92521


AUTHORIZATION REQUIRED

 PR EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER) CHIP, STAR, STAR KIDS CHIP PERINATE 8/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92522


AUTHORIZATION REQUIRED

 PR EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE CHIP, STAR, STAR KIDS CHIP PERINATE 8/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92523


AUTHORIZATION REQUIRED

 PR EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION CHIP, STAR, STAR KIDS CHIP PERINATE 8/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92524


AUTHORIZATION REQUIRED

 PR BEHAVIORAL & QUALIT ANALYSIS VOICE AND RESONANCE CHIP, STAR, STAR KIDS CHIP PERINATE 8/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92526


AUTHORIZATION REQUIRED

 PR ORAL FUNCTION THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

92610


AUTHORIZATION REQUIRED

 PR EVAL,ORAL & PHARYNGEAL SWALLOW FUNCTION CHIP, STAR, STAR KIDS CHIP PERINATE 8/1/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.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

97010


AUTHORIZATION REQUIRED

 PR HOT OR COLD PACKS THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.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

97012


AUTHORIZATION REQUIRED

 PR MECHANICAL TRACTION THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 MUST BE INCLUDED ON AUTH REQUESTS FOR THERAPY TELEHEALTH, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX,
MD GUIDELINE 1: Therapy-Guide.pdf,
MD GUIDELINE 2: Therapy-Referral-Review-by-Ordering-Physician-Attestation-Form.pdf,
MD GUIDELINE 3: Therapy-Request-Checklist.PDF,
MD GUIDELINE 4: THERAPY-TELEHEALTH.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 6/6/2023
Page 1 of 7 (63 items)Prev1234567Next