Prior Authorization process update for Case Management for Children and Pregnant Women (CPW) Services

Date: October 14, 2026

Attention: Providers

Effective date: November 15, 2026

Call to action: Texas Children’s Health Plan (TCHP) is notifying network providers that, effective November 15, 2026, the prior authorization requirements for Case Management for Children and Pregnant Women (CPW) services billed under procedure code G9012 and applicable modifiers will be updated.

To avoid delays in processing, TCHP strongly encourages providers to submit prior authorization requests electronically through the Texas Children's Link Provider Portal. Also, if necessary, the request, along with all required supporting documentation and essential information, may be submitted via fax to 832-825-8760.

This prior authorization requirement applies to eligible CPW services provided to children from birth through age 20 and to pregnant individuals of any age who meet CPW program eligibility criteria. CHIP and CHIP Perinatal members are not eligible for CPW services and are therefore not impacted by this change. Please note that the initial comprehensive CPW visit remains exempt from prior authorization requirements. Providers should ensure all subsequent services requiring authorization are submitted in accordance with TCHP prior authorization guidelines and applicable state program requirements.

Background: The CPW program is a Medicaid benefit that provides health-related case management services to children from birth through age 20 with a health condition or health risk, and to pregnant individuals of any age with a high-risk condition. With the passage of House Bill 1575, case management also encompasses nonmedical health-related needs for eligible pregnant individuals, such as housing, food, transportation, and childcare. This prior authorization requirement helps TCHP ensure CPW services are medically necessary and not duplicative of existing service coordination or case management services already available to the member.

How this impacts providers: Effective 11/15/2026, CPW providers must submit a prior authorization request to TCHP for certain CPW services billed under procedure code G9012 before rendering services. Providers should be aware of the following:

• Providers should begin submitting prior authorization requests for CPW services for dates of service on or after November 15, 2026.
• The initial comprehensive visit does not require prior authorization.
• Prior authorization requests for follow up CPW visits must be submitted with required documentation: TCHP Prior Authorization Form, CPW form(s), consent form, assessment, and service plan. 
• Supporting documentation must demonstrate medical necessity. The number of authorized CPW visits will be considered based on the member’s level of need, level of medical involvement, and complicating psychosocial factors.
• TCHP will review the members’ service plan to determine whether services are being provided in person or require coordination with external agencies (e.g., CPS, school).
• CPW services cannot duplicate TCHP Service Coordination or TCHP Case Management services. 
• Requests that do not meet medical necessity criteria (below) or are deemed a duplication of services will be reviewed by TCHP’s Medical Director.
• Procedure code G9012 is used for all CPW services. Modifiers must be used to identify which service component is being provided.

Medical Necessity Criteria: Prior authorization requests must demonstrate medical necessity including:

• Pregnant individuals of any age who have a high-risk pregnancy, medical conditions, or psychosocial conditions that place the individual and her fetus at greater-than-average risk for complications during pregnancy, delivery, or after childbirth; or
• Children birth through 20 years of age who have, or are at risk for, a health condition, illness, injury, or disability resulting in a limitation of function, activities, or social roles compared to healthy same-age peers in the areas of physical, cognitive, emotional, or social growth and development; and
• Need assistance gaining access to necessary medical, social, educational, or other services related to the high-risk condition.
• Desire for case management services 

Allowable Visit Limits

Resources: 
Texas Health and Human Services CPW

Texas Administrative Code CPW

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

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