Quick Reference Guide | Texas Children's Health Plan

For a printable PDF of our Provider Quick Reference Guide, please click here.

Customer Service

Claim inquiry, questions, and information.
Information about CHIP or STAR products.
Eligibility/benefits questions on all products.

Phone: 832-828-1004
Toll free: 1-877-213-5508
Telephone TouCHPoint: 832-828-1007
Fax: 832-825-8777

Texas Children’s Health Plan Fraud and Abuse Hotline

Phone: 832-828-1320
Fax: 832-825-8722
Email: FraudandAbuse@TCHP.us

Provider Relations

Inquiries regarding Texas Children’s Health Plan policies and procedures.

Contract clarification/interpretation.
Fee schedule inquiries.
Change of address/phone number/tax identification number.
Requests for supplies (forms, directories, etc.).
Information on provider educational in-services.
Requests for information on accessing Provider TouCHPoint, Texas Children’s Health Plan’s web-based provider portal for claims, authorizations, eligibility, and information.

Phone: 832-828-1008
Toll free: 1-800-731-8527
Fax: 832-825-8750
Website: www.TexasChildrensHealthPlan.org/For-Providers
Email: tchpprovrel@texaschildrens.org

Texas Children’s Health Plan Pharmacy Information

Navitus website: www.navitus.com
Navitus toll free provider hotline: 1-877-908-6023
Navitus customer care: 1-866-333-2757

Provider Portal

Texas Children’s Health Plan’s new online portal offers you convenient 24-hour access to your patient’s information. Through the Provider Portal, you can view a Texas Children’s Health Plan member’s eligibility, check the status of your claim, submit an authorization, look up an explanation for CPT, diagnosis, or modifier codes, and more.

For a printable PDF of our Provider Portal Training Guide, click here.

For password lockouts: 1-877-814-9909

First-time users, please have your Office Manager complete the online registration form.

Only one registration form is necessary per office.

Cultural Sensitivity

Cultural sensitivity refers to the ability of individuals and systems to provide services effectively to people of all cultures, races, ethnic backgrounds, and religions in a manner that recognizes values, affirms and respects the worth of the individuals, and protects and preserves the dignity of each. Texas Children’s Health Plan’s interpretive services will help to provide care in culturally competent manner.

Texas Children’s Health Plan has a mechanism in place to allow Members with Special Health Care Needs to have direct access to a specialist as appropriate for the Member’s condition and identified needs, such as a standing referral to a specialty physician.

Envolve Vision

CHIP: 1-844-520-3711
STAR: 1-844-683-2305
STAR Kids: 1-844-212-7269

Dental Services

DentaQuest: 1-800-685-9971
MCNA Dental: 1-800-494-6262

Texas Children’s Health Plan value added benefit:

FCL Dental (STAR members over 21): 1-866-548-8123

Care Coordination, Case, and Disease Management

Referrals for assistance with chronic, complex conditions, or maternity. Requests for birthing and health education classes.

Phone: 832-828-1430
Fax: 832-825-8745

Asthma / Obesity / Diabetes education:

Phone: 832-828-1004
Fax: 832-825-8705

Nurse Family Partnership:

Phone: 832-828-1274
Fax: 832-825-8710

Nurse Help Line

Members have access to registered nurses 24 hours a day, 7 days a week.

Texas Children’s Health Plan Nurse Help Line: 1-800-686-3831

Emdeon–EFT Enrollment and Questions

Visit the ePayment website www.emdeon.com/epayment to sign up today.

Emdeon EFT telephone number: 866-506-2830

Electronic Claims Submission

HIPAA-compliant electronic claims filing. Texas Children’s Health Plan does not accept electronic UB92 claims for STAR through Availity.

CHIP

Emdeon and Availity: 76048

STAR

Emdeon: 75228
Availity: TXCSM

Claims Filing Information

Filing deadlines for all products is 95 days from date of service.

Texas Children’s Health Plan Claims
PO Box 300286
Houston, TX 77230-0286

Claims Appeals

All appeals must be received within 120 days from the previous health plan Explanation of Payment (EOP). Please use the appeal coversheet from Texas Children’s Health Plan Provider Manual.

Texas Children’s Health Plan
Attn: Appeals
PO Box 300286
Houston, TX 77230-0286

Prior Authorizations

The prior authorization process is used to evaluate the medical necessity of a procedure, course of treatment, appropriate level of service, and length of stay prior to the provision of services. A copy of the prior authorization request form can be found in the Provider Manual. Prior authorizations should be requested 3 to 5 days prior to the scheduled date of service. Current services requiring authorization are listed below, but please check with Texas Children’s Health Plan Utilization Management at 832-828-1004, option 5 or Provider TouCHPoint at www.tchp.us/providers for updates to this list:

Medical Authorizations

All genetic testing
All out-of-network services
Ambulance services (non-emergent transport)
Augmentative Communication Devices
Baclofen injections/pump
Bariatric Surgery
Botox Injections
Chemotherapy non-FDA approved
Circumcision greater than 1 year of age
Cochlear Implant
Contact lenses due to disease process
Cosmetic Surgery
Cranial Molding Orthosis (Helmets)
Dental Medically necessary (except for cleft palate)
Gait trainer
Home Health Care
Hospital grade Blood Pressure Monitors in home use
Hospital Beds and accessories
Hospital Inpatient care
Makena Injections
Nutritional Supplements
Oral Surgery
Organ Acquisition
PET Scans
Prescribed Pediatric Extended Care Centers
Private Duty Nursing in home
Prosthetics
Skilled Nursing facility
SPECT Scans
Therapy – Physical, Occupational,Speech
(including initial Eval)
TMJ diagnosis and treatment
Transplant Evaluation
Vision Care, medically necessary
Wheelchairs and accessories

Behavioral Health Authorizations

All out-of-network services
Inpatient Care
Intensive Outpatient Treatment
Neuropsychological Testing
Outpatient Behavior Health visits greater than 30 (per Calendar year)
Partial Hospitalization
Psychological Testing (excluding initial eval)
Residential Treatment Facility
Targeted Case Management
Substance Use Disorder Treatment (excluding eval)

Utilization Management

Urgent authorization requests:

Phone: 832-828-1004, option 5
Toll free: 1-877-213-5508
Fax: 832-825-8760

Behavioral Health Authorizations

Members and/or PCPs can self refer to a participating behavioral health provider.

Phone: 832-828-1004, option 5
Toll free: 844-291-7505
Fax: 832-825-8767

Referrals

Patients should be referred to in-network specialists. When Texas Children’s Health Plan members are referred for specialty care to an in-network specialist, it is not necessary to complete a referral form. Members may self-refer for in-network OB/GYN services, behavioral health, family planning, and any Texas Health Steps provider.

Imaging Services

It is not necessary to use a referral form for imaging services. Providers should refer members for imaging services using in-network providers, on an appropriate vendor requisition form. Participating providers, which may vary by product, include:

Woodlake MRI & Diagnostics
Universal MRI & Diagnostics
Any contracted hospital

Laboratory Services

It is not necessary to use a referral form for laboratory services. Providers should refer members for laboratory services to an in-network laboratory, using an appropriate vendor requisition form. Participating providers, which may vary by product, include: