Annual Utilization Management Notice to All Providers

Attention: All ProvidersProviders 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. Affirmative Statement about Incentives As a reminder, Texas Children’s Health Plan (TCHP) Utilization Management (UM) decision-making is based on our Policies, Procedures, and Guidelines. They are based only on appropriateness of care and service and the existence of coverage. TCHP does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care. TCHP does not offer financial incentives for UM decision makers that encourage decisions that result in under-utilization. TCHP does not hire, promote, or terminate based on the likelihood that a practitioner will support or tend to support the denial of benefits. Availability of Criteria to Practitioners It is the policy of Texas Children’s Health Plan to use written criteria based on clinical evidence for appropriate case application in adjunct to a review of individual circumstances and local health system structure when determining medical appropriateness of health care services. Texas Children’s Health Plan has developed Utilization Management guidelines that are objective and based on medical evidence to serve as criteria for the determination of medical necessity for services that require prior authorization. The goal of our UM guidelines is to encourage the highest quality care from the right provider in the right setting. Providers may access the guidelines in any of the following methods:

• Directly from our website: https://www.texaschildrenshealthplan.org/for-providers/provider-resources/prior-authorization-information
• Providers may log in to the Provider Portal at org/for-providers
• Contact Texas Children’s Health Plan Provider Network Management Department at 832-828-1008 or toll-free at 1-800-731-8527.

How to Contact Utilization Management Our Provider Services team is ready to take your call from 8 a.m. to 5 p.m., Monday through Friday at 832-828-1004 (option 3) or 1-877-213-5508 (option 3). After hours, on weekends and holidays, our answering service is ready to help you and/or take your messages. A Provider Services team member will return your call the next business day.Messages left for UM staff after hours by phone are returned the next business day. Texas Children’s Health Plan offers TDD.TTY services for deaf, hard of hearing, or speech impaired members and providers. For TDD assistance, please call 1-800-735-2989 or 7-1-1. Language line assistance is available to UM staff, if needed, in discussion with members or practitioners for any UM issue. Next steps for providers: Providers should share these reminders 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.