Out-of-Network (OON) Policy & Procedure Reminder

Date: January 30, 2026

Attention: All Providers

Call to action: Texas Children’s Health Plan (TCHP) would like to remind providers that OutofNetwork (OON) services, authorization standards, accesstocare expectations, and continuityofcare obligations, in alignment with the Uniform Managed Care Contract (UMCC) and TCHP policy guidelines.

Timely and Adequate Access to OON Services

TCHP will provide Members with timely and adequate access to OON services only when medically necessary services are not available within the contracted TCHP network.

Accesstocare determinations must comply with UMCC travel time and distance parameters, measured from the Member’s listed address to the point of service.

• If an innetwork provider is identified who meets UMCC time/distance standards, the OON request will receive a nonmedicalnecessity administrative denial.

OutofServiceArea Requests (Requiring Prior Authorization)

The following may qualify for OON authorization when supported by appropriate documentation:

• Urgent services for conditions that arise while the Member is out of the service area, when it is not reasonable to seek care from an innetwork provider.
• Poststabilization care required to maintain clinical stability before transfer back to a participating provider.
• Care for Members who relocate out of service area, approved through the end of the period for which the Member remains enrolled.
• Second opinions or subsequent medically necessary treatment (medical, surgical, or behavioral health) when validated by the TCHP Medical Director.
• Covered services not able to be performed by network providers/facilities.
• Covered services unavailable within reasonable time and distance standards, appropriate to the Member’s condition and UMCC requirements.
• Clinical risk or hardship, when validated by the TCHP Medical Director.

Required Documentation for OON Authorization Requests

When requesting authorization for services to be rendered by an OON provider:

• The requesting provider must be innetwork, and documentation must clearly reflect this.
• All applicable clinical documentation supporting the need for OON services must be submitted with the request.
• Required documentation should align with the TCHP Guidelines specific to the requested service category.

Circumstances in Which OON Providers Will Not Be Approved

TCHP will not authorize OON services under the following conditions:

• Services are available through an innetwork provider who is able to meet UMCC time and distance standards.
• An innetwork provider is currently providing the requested service(s).
• Second opinion services are available in the network within UMCC access parameters.
• The Member has selfreferred to an OON provider.
• Providers currently in contract negotiations; these providers remain OON until the contracting process is fully executed.

Discontinuation of OON Approval

OON authorization may no longer be approved if/when services become available from an innetwork provider who meets UMCC travel time and distance standards.

Indian Health Care Provider (IHCP) Provision

TCHP allows Indian Members to receive covered services from an OON Indian Health Care Provider (IHCP) for which the Member is otherwise eligible, in compliance with federal access protections.

Next step for Providers: Providers must follow the guidance provided in this communication and adjust their operations accordingly to comply.

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org. 

For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.