Date: December 5, 2025
Attention: All Providers
Texas Children’s Health Plan (TCHP) has partnered with EXL Services (EXL) to conduct ongoing retrospective audits. This collaboration helps ensure billing accuracy and compliance with program requirements aligning to Texas Medicaid regulations and prevailing industry standards.
The EXL auditing team includes: Registered Nurses, Licensed Vocational Nurses, Clinical Social Workers, Master Level Clinical Social Workers, Certified Professional Coders, Certified Inpatient Coders, and Claims Management Analysts.
EXL is currently conducting audits, and will introduce the following audit programs:
- High Cost Drug – a review process to ensure the dosage administered is billed appropriately. In addition to validation of units, the auditor reviews the coding of the drug to ensure the correct HCPCS is billed.
- Durable Medical Equipment – a review process to ensure the services provided were ordered by a provider, appropriately invoiced and accurately paid.
- Outpatient – a review process to ensure the coding is documented and billed appropriately.
- Diagnosis Related Group – a review process to ensure the code assignment using clinical documentation is valid based on diagnosis, sequencing and coding guidelines.
- Short Stay – a review process to ensure the appropriate patient status is assigned and documented based on the different types of care (ED, observation, inpatient).
- Home Health – a review process to ensure the service provided (plan of care, homebound status, physician orders, therapy) is accurate and aligns to the supporting documentation provided by the agency.
- Behavioral Health – a review process to ensure core clinical elements like intake, assessments, and individualized treatment plans are documented thoroughly and meets correct coding guidelines.
Helpful Resources:
- The most secure way to submit your medical records, appeals, obtain status of audits, or locate the provider user manual is through the EXL Provider Portal available at: https://exlhealthproviderportal.exlservice.com/
- Review our FAQ Guide for answers to common questions about this collaboration.
How this impacts providers: If selected for an audit, you will receive a letter from EXL requesting medical records for a specific date of service (DOS). Please comply promptly to avoid delays.
Next steps for providers: Providers are encouraged to share this communication with their staff and be on the lookout for a potential audit notification letter from EXL.
If you have any questions or require additional information, please reach out to your assigned Account Lead or Provider Relations Liaison (PRL). If you’re unsure who your Account Lead or PRL is, you can find contact details on our Meet Our Team page.
Thank you for your continued partnership as we work to improve the quality and accuracy of our claims processing.
For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.
