Upcoming Custom Edit Implementation for DRG Validation

Date: June 10, 2025

Attention: All Providers

Effective date: July 23, 2025

Call to action: Texas Children’s Health Plan (TCHP) is notifying providers and their designated clearinghouses about a new custom edit that will go live on July 23, 2025. TCHP previously notified providers of custom edit implementation on April 23, 2025, click here to access that communication. This notification is specifically pertaining to DRG Validation.

How this impacts providers: Effective July 23, 2025, Texas Children’s Health Plan will implement a new custom edit through Availity, our claims clearinghouse:

• Diagnosis Related Group (DRG) Validation

DRGs will be validated against the Texas APR-DRG Grouper Files published yearly by TMHP to ensure that each DRG is valid and in compliance with the most recent state-provided data.

Operational Support:

Availity Customer Support (ACS) supports providers with all Availity Essentials Portal actions. Provider’s clearinghouse are welcome to contact Availity at 1-800-282-4548 for one of the reasons below. Availity call center is available Monday – Friday, 8am to 8pm EST. Examples include:

• Portal registration
• User access/ Account assistance
• Transaction submissions
• Portal error messages
• Claim rejection

Texas Children’s Health Plan Call Center supports providers with all ‘data’ related provider inquiries. Providers can contact the Call Center at 832-828-1004 or toll-free at 1-800-731-8527. Examples include:

• Claim denial
• Benefit coverage details
• Prior Authorization details
• Claim payment questions
• Network details

Next step for Providers: Providers should share this communication with their billing staff and clearinghouse.

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

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