Date: December 31, 2024
Subject: Prescribed Pediatric Extended Care Center (PPECC) Benefit Criteria Updates for Texas Medicaid
Effective date: December 1, 2024
Call to action: The purpose of this communication is to inform providers that Texas Children’s Health Plan (TCHP) is in alignment with the Prescribed Pediatric Extended Care Center (PPECC) benefits have been updated to support the implementation of HB 3550, 88th Legislature, Regular Session, 2023. The benefit changes are effective December 1, 2024.
The benefit updates include changes to the following criteria:
The Plan of Care (POC) requirements
Prior Authorization Requirements
Recertification or Extension Request
Appeal of Authorization Decisions
Documentation Requirements
Coordination with Private Duty Nursing
Reimbursement
For more information on the prior authorization requirements and the benefit updates described please review the following.
Texas Medicaid Provider Procedures Manual, Children’s Services Handbook 2_04_Childrens_Services.fm (tmhp.com)
Texas Medicaid Provider Procedures Manual, Home Health and Private Duty Nursing Services Handbook 2_10_HH_Nursing_and_PDN_Srvs.fm (tmhp.com)
TMHP Bulletin released 10/14/24: PPECC Benefit Criteria Updates Effective December 1, 2024 PPECC Benefit Criteria Updates Effective December 1, 2024 | TMHP
TCHP Prior Authorization Guidelines: Prior Authorization Information | Texas Children's Health Plan (texaschildrenshealthplan.org)
How this impacts providers: TCHP is following Texas Medicaid’s guidance for prior authorization review and will adhere to the updated criteria for medical necessity for PPECC services.
Next step for Providers: Providers should share this communication with their staff and adhere to the updates.
If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org.
For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts.