TCHP Prior Authorization Requirements

Date:  July 1, 2019Subject: TCHP Prior Authorization Requirements Effective October 1, 2019, TCHP has updated the prior authorization listing. Please note there are some key changes for providers.   Added:           Case by Case Added Services This category includes CPT/HCPCS codes that are listed as not payable in the TMHP fee schedule. Clinician Administered Drugs that Require Authorization Please refer to the Prior Authorization Reference Information document for specific codes that fall under this category. This document can be found at: https://www.texaschildrenshealthplan.org/for-providers/provider-resources   DME Repair (K0739) when greater than 35 unitsMiscellaneous DME (E1399) when billed amount is greater than $500   Removed: These items are no longer listed separately as they now fall into the category of Clinician Administered Drugs that Require Authorization. These services will continue to require prior authorization.

• Botulinum Toxin Injections
• High cost (>$50,000) injectable drugs in the outpatient setting (e.g. nusinersen, kymriah, exondys 51), excluding FDA approved chemotherapy
• Hydroxyprogesterone caporate injections
• Non-FDA Approved Medications

The new TCHP prior authorization list and our latest search & find companion guide will also be posted at: https://www.texaschildrenshealthplan.org/for-providers/provider-resources If there are further questions, please contact the Provider Relations Department at 800-731-8527.