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:

Page 1 of 5 (44 items)Prev12345Next
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 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
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 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
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 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
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 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
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 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97014


AUTHORIZATION REQUIRED

 PR ELECTRIC STIMULATION THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
MD GUIDELINE 1: CARPAL-TUNNEL-SYNDROME.PDF,
MD GUIDELINE 2: LUMBAGO-OF-PREGNANCY.PDF,
MD GUIDELINE 3: PATELLOFEMORAL-PAIN-SYNDROME.PDF,
MD GUIDELINE 4: Therapy-Guide.pdf,
MD GUIDELINE 5: THERAPY-REFERRAL-REVIEW-BY-ORDERING-PHYSICIAN-ATTESTATION-FORM.PDF,
MD GUIDELINE 6: THERAPY-REQUEST-CHECKLIST.PDF,
MD GUIDELINE 7: THERAPY-TELEHEALTH.PDF		 CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97016


AUTHORIZATION REQUIRED

 PR VASOPNEUMATIC DEVICE THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97018


AUTHORIZATION REQUIRED

 PR PARAFFIN BATH THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97020


AUTHORIZATION REQUIRED

 PR MICROWAVE THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM, 05/31/2024
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

97022


AUTHORIZATION REQUIRED

 PR WHIRLPOOL THERAPY CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
MODIFIER: MODIFIER 95 REQUIRED ON CLAIM FOR THERAPY TELEHEALTH VISITS, RENDERING PROVIDER: AUTH IS REQUIRED IF REFERRED TO PROVIDER IS NOT DRISCOLL CHILDREN'S HOSPITAL, EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR. PROCEDURE CODE 97010 IS NOT A PAYABLE BENEFIT PER THE TMHP FEE SCHEDULE; IT IS PART OF A BUNDLED SET OF CODES AND WILL NOT BE CONSIDERED SEPARATELY FOR REIMBURSEMENT. TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM,
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, 05/31/2024
Page 1 of 5 (44 items)Prev12345Next