DME/equipment/supplies exceeding Texas Medicaid Limitations

Effective October 1, 2019, Texas Children’s Health Plan will implement a prior authorization process for providers to request prior approval to provide DME/Equipment/Supplies to members 20 years of age and under in excess of benefit limitations. Texas Children’s Health Plan applies benefit limitations for DME/Equipment/Supplies in accordance with the Texas Medicaid Provider Procedure Manual (TMPPM) for all members eligible to receive the benefit, except for the following:   Next steps for providers: DME/Equipment/Supplies for a member who is 20 years of age or younger does not require a prior authorization when billed within the benefit limit, however to exceed the benefit limitation a provider may submit a prior authorization request justifying the medical necessity of exceeding the benefit limitation to the TCHP Utilization Management department. Prior authorization requests can be made by visiting our website, www.texaschildrenshealthplan.org/for-providers and completing the Standard Prior Authorization Form and faxing it to 832-825-8760 or toll-free 1-844-473-6860. Texas Children’s Health Plan will require documentation to support medical necessity as per the current TMPPM for the item requested. DME/Equipment/Supplies listed on our current Prior Authorization list will not be impacted.  Providers can continue to justify the medical necessity of exceeding the Texas Medicaid limitation in their prior authorization request.