Benefit Limitations for Colony-Stimulating Factors Will Change

Date: August 26, 2025

Attention: Providers

Effective date: September 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after September 1, 2025, Texas Medicaid will change some benefit limitations for colony-stimulating factors.

How this impacts providers: The following colony-stimulating factor procedure codes will no longer be diagnosis-restricted:

Billing Guidelines

Texas Medicaid will deny claims for the reimbursement of the following procedure codes when the same provider submits a claim for specific procedure codes with the same date of service:

Texas Medicaid managed care organizations (MCOs) like Texas Children’s Health Plan (TCHP) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO/TCHP. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should reference a member’s specific MCO/TCHP for information on these items. For TCHP, this information can be found on the provider page available at https://www.texaschildrenshealthplan.org/providers.

Next step 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: www.texaschildrenshealthplan.org/provideralerts.