Date: July 7, 2023
Attention: All Providers
Effective Date: July 1, 2023
Call to action:Texas Children’s Health Plan (TCHP) would like to inform providers that effective July 1, 2023, noninvasive prenatal screening (NIPS) benefits will change for Texas Medicaid.
How this impacts providers: Effective July 1, 2023, major changes to this medical benefit include the following:
- Updated benefit eligibility criteria
- Removed fee-for-service (FFS) prior authorization requirement
NIPS is a benefit for members who have a confirmed intrauterine singleton pregnancy dated at least ten weeks gestation. Members will no longer be required to meet specific high-risk criteria.
Procedure codes 81420 and 81507 will no longer require prior authorization in FFS Medicaid, but will remain limited to once per pregnancy. Additional screenings will not be reimbursed.
For additional information on benefit limitations and coverage requirements, reference Texas Medicaid Provider Procedure Manual (TMPPM) Gynecological, Obstetrics and Family Planning Title XIX Services Handbook,sections 5.4 and 5.5, as outlined below.
NIPS limitations:
- Procedure codes 81420 and 81507 are restricted to female clients only who are 10 through 55 years of age.
- Procedure code 81420 will be denied when billed during the same pregnancy as procedure code 81507, by any provider.
- Claims that have been paid for procedure code 81420 are subject to recoupment if procedure code 81507 is submitted later for the same pregnancy.
Non-covered services:
The following NIPS services are not benefits of Texas Medicaid:
- NIPS as part of a routine prenatal laboratory assessment
- NIPS if performed without informed patient choice and pre- and post-screen genetic counseling from a qualified professional
- NIPS for women who do not meet the criteria outlined above
- NIPS for women with multiple gestations (e.g., twins, triplets, etc.)
- NIPS for screening of chromosomal microdeletion syndromes
- NIPS for screening of trisomy other than T13, T18, or T21
- NIPS for sex determination, paternity determination, or non-medical reasons
- NIPS is not reimbursed with procedure code 81599
Next steps for providers: Providers should share this communication with their staff.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
