Prior Authorization Guideline Update Notification

Call to action: The purpose of this communication is to inform providers of changes to the Prior Authorization Guidelines.

As a reminder, all of the Texas Children’s Health Plan prior authorization information including Prior Authorization Guidelines are available on this webpage, https://www.texaschildrenshealthplan.org/for-providers/prior-authorization-information.

How this impacts providers: Updates and changes to the guidelines are as follows:

Guideline	Changes
TCHP Orthoses Guidelines	Updated criteria for foot orthoses, clarifying additional criteria for foot inserts
TCHP Single Photon Emission Computed Tomography (SPECT) Guidelines	Minimal revisions to language and format for readability. Added non-Cardiac indication, initial/subsequent staging for Thyroid Cancer
TCHP Secretion and Mucous Clearance Devices Guidelines	No change to criteria
TCHP Organ Tissue Transplant Guidelines	Clarified limitation on donor expenses  Added section on covered indications for stem cell transplants per Texas Medicaid Provider Procedures Manual (TMPPM) Removed reporting requirement to Stem Cell Transplant Outcome Database as this is more restrictive than TMPPM
Benefit change effective 9/1/2024: TCHP Telemonitoring Guideline	Added updates to align with Texas Medicaid Provider Procedures Manual (TMPPM) changes effective 9/1/24.  Only one risk factor is needed (previously 2)  Allowed practitioners can order telemonitoring (in addition to physicians) New telemonitoring request form is used  FQHC and RHC can provide telemonitoring
TCHP Prescribed Pediatric Extended Care Center (PPECC) Guidelines	Added provider requirement for PPECC interdisciplinary conferences every 90 days per TMPPM Documentation requirement for signed consent by member/legal authorized representative for initial PPECC requests moved to separate section.
TCHP Sleep Studies Guidelines	Added Section 1 clarifying prior authorization requirements: Prior authorization is not required for in network providers; Out of Network (OON) provider requests are reviewed against OON Guidelines and Sleep Study Guidelines

Next step for Providers: Providers should become familiar with the prior authorization guidelines and check them regularly for further updates.

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.