Quick Reference Guide | Texas Children's Health Plan
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Quick Reference Guide

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

Report Fraud, Waste and/or Abuse

Suspected fraud, waste or abuse (FWA) by recipients or providers can be reported to the Office of Inspector General (OIG) and/or Texas Children’s Health Plan’s Special Investigations Unit (SIU).

Office of Inspector General: FWA Reporting
Website: https://oig.hhsc.texas.gov/report-fraud-waste-or-abuse

Texas Children’s Health Plan: FWA Reporting

Hotline Phone Number: 832-828-1320
Fax Number: 832-825-8722
Email: TCHPSIU@texaschildrens.org

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: 832-828-1004
Toll free: 1-800-731-8527
Fax: 832-825-8750
Website: www.TexasChildrensHealthPlan.org/For-Providers
Email: providerrelations@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

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

  1. All genetic testing
  2. All out-of-network services
  3. Ambulance services (non-emergent transport)
  4. Augmentative Communication Devices
  5. Baclofen injections/pump
  6. Bariatric Surgery
  7. Botox Injections
  8. Chemotherapy non-FDA approved
  9. Circumcision greater than 1 year of age
  10. Cochlear Implant
  11. Cosmetic Surgery
  12. Cranial Molding Orthosis (Helmets)
  13. Dental Medically necessary (except for cleft palate)
  14. Gait trainer
  15. Home Health Care
  16. Hospital grade Blood Pressure Monitors in home use
  17. Hospital Beds and accessories
  18. Hospital Inpatient care
  19. Makena Injections
  20. Nutritional Supplements
  21. Oral Surgery
  22. Organ Acquisition
  23. PET Scans
  24. Prescribed Pediatric Extended Care Centers
  25. Private Duty Nursing in home
  26. Prosthetics
  27. Skilled Nursing facility
  28. SPECT Scans
  29. TMJ diagnosis and treatment
  30. Transplant Evaluation
  31. Vision Care, medically necessary
  32. Wheelchairs and accessories
      

  Behavioral Health Authorizations

  1. All out-of-network services
  2. Inpatient Care
  3. Intensive Outpatient Treatment
  4. Neuropsychological Testing (exceeding limits)
  5. Outpatient Behavior Health visits greater than 30 (per Calendar year)
  6. Partial Hospitalization
  7. Psychological Testing (exceeding limits)
  8. Residential Treatment Facility
  9. Targeted Case Management
  10. Substance Use Disorder Treatment (excluding assessment, outpatient treatment services unless limits exceeded, and Medication Assisted Treatment 

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

Providers should refer members for laboratory services to our exclusive reference lab provider, Quest Diagnostics. To access a specific list of labs on our pre-approved list that may be run in a network provider’s office click here:
http://www.thecheckup.org/2020/04/27/provider-alert-approved-in-office-lab-list/

Phone Numbers for State Programs

  • CHIP Help Line: 1-800-647-6558
  • Early Childhood Intervention (ECI): 1-800-628-5115
  • Family Planning Program: 512-458-7796
  • Medicaid Program Member Verification (NAIS): 1-800-925-9126
  • Medical Transportation Program (MTP): 1-877-MED-TRIP (633-8747)
  • STAR Help Line: 1-800-964-2777
  • STARLink Advocate for Medicaid: 1-866-566-8989
  • Texas Health Steps: 1-877-847-8377
  • Women, Infants & Children Program (WIC): 1-800-942-3678
  • Vaccine for Children (VFC): 1-800-252-9152

Behavioral Health Hotline

Members have access to 24/7 crisis assistance
STAR: 800-731-8529
CHIP: 800-731-8528

Provider and Vendor Check Payments (Refunds)

Texas Children's Health Plan
P.O. Box 841976
Dallas, TX 75284-1976

Clinical Practice Guidelines

Available online at www.tchp.us/providers/ or by contacting Provider Relations for a faxed copy.