Prior Authorization Requirements for Incontinence Supplies

Date: March 15, 2021Attention: All ProvidersEffective Date: December 22, 2020Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Texas Children’s Health Plan (TCHP) would like to inform network providers of the prior authorization requirements for incontinence supplies. How this impacts providers: Incontinence supplies (diapers, wipes, and under pads) may be considered for members age 3 and younger and with a medical condition that results in increased urine or stool output beyond what is typical for this age group, including but not limited to:

Short bowel syndrome, Chron’s disease, Celiac disease, Diabetes insipidus, Radiation enteritis, or certain metabolic conditions.

Quantity limitations per TMPPM apply to this age group: diapers (240 per month), wipes (2 boxes per month), and underpads (120 per month).
Wipes are for members receiving diapers/briefs/pull-ons and under pads are for members receiving diapers/briefs/pull-ons/liners/urine or bowel collection devices.
Gloves used to change diapers and briefs are not considered medically necessary unless the member has skin breakdown or a documented disease that can be transmitted through urine or stool.
For all ages, prior authorization is required over the limit requests: diapers (240 per month), wipes (2 boxes per month), and under pads (120 per month).

Next steps for providers: Providers should share this prior authorization guidance with their staff. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org. For access to all provider alerts, log into:www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.