List of Services Requiring Prior Authorization

List of Services Requiring Prior Authorization

CHIP CHIP PERINATE STAR
Biologicals over $500 administered in office or outpatient setting
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Biosimilars over $500 administered in office or outpatient setting
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Chemotherapy over $500 administered in office or outpatient setting
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Gene therapy
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Hydroxyprogesterone (17-P)
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Injectable immunoglobulins over $500 administered in office or outpatient setting
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Injectable intravitreal (eye) medications over $500 administered in office or outpatient setting
Needs Prior Authorization

COVERED

Needs Prior Authorization
Makena over $500 administered in office or outpatient setting
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
CHIP CHIP PERINATE STAR
Dental Anesthesia (deep sedation or general anesthesia for dental procedures for children six years of age or younger)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
DME greater than $300/item
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
DME or supplies in excess of benefit limitations (see TMHP Provider Procedures Manual)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
DME rentals longer than two months
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Enteral formulas and nutritional supplies/supplements
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Orthotics (over $200/item)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Prosthetics (over $200/item)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization

*Initial evaluation does not require prior authorization

CHIP CHIP PERINATE STAR
Private Duty Nursing *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Skilled Nursing require *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
CT scan
Does not need
Prior Authorization

Does not need
Prior Authorization

Does not need
Prior Authorization
Fetal Echocardiography only the following codes (76825, 76826, 76827, 76828)
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
MRI
Does not need
Prior Authorization

Does not need
Prior Authorization

Does not need
Prior Authorization
PET Scan require a prior authorization
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Sleep Studies require a prior authorization
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
Ambulatory Surgical Center Procedures
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Chemotherapy
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Dialysis
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Heart Cath procedures
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Intensive Outpatient Hospitalization
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Partial Hospitalization Program
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Prescribed Pediatric Extended Care Center (PPECC)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Residential Treatment Center
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Radiation Therapy
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Wound Clinic Services
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization

*Notification of inpatient admission is required within one business day after admission

CHIP CHIP PERINATE STAR
Deliveries extending beyond 2 days after vaginal/3 days after cesarian section
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Deliveries-Routine do not require a prior authorization
Does not need
Prior Authorization

Does not need
Prior Authorization

Does not need
Prior Authorization
Elective/Scheduled procedures *
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Emergent Medical admission do not require a prior authorization *
Does not need
Prior Authorization

Does not need
Prior Authorization

Does not need
Prior Authorization
Emergent Psychiatric admission do not require a prior authorization *
Does not need
Prior Authorization

NOT COVERED

Does not need
Prior Authorization
Inpatient hospice *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Nursery stay in which newborn remains inpatient after mother is discharged
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Rehabilitative *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Substance Abuse Treatment *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
Elective procedures
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Scheduled procedures
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
CHIP CHIP PERINATE STAR
Allergy injections when limits are exceeding (see Texas Medicaid Provider Procedures Manual for limitations)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
BRCA screening (excluding cpt 82105)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Emergency Room Care does not require prior authorization
Does not need
Prior Authorization

Does not need
Prior Authorization

Does not need
Prior Authorization
Family Planning does not require prior authorization (contraceptive drugs/devices are not a benefit for CHIP)
NOT COVERED

Does not need
Prior Authorization
Genetic testing
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Hearing Aids
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Implantable Devices
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Primary Care Physician office visit do not require prior authorization
Does not need
Prior Authorization

Does not need
Prior Authorization

Does not need
Prior Authorization
Specialist-to-Specialist Referral
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Transfers – non-emergent facility to facility outside of El Paso service area
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Venous Procedures (in-office/outpatient)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
All out-of-network medical and behavioral services (except emergent) require a prior authorization
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization

*Initial evaluation does not require prior authorization

CHIP CHIP PERINATE STAR
Occupational Therapy (OT) *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Physical Therapy (PT) *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Speech Therapy (ST) *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Re-evaluation for OT, PT, and ST
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization

*Initial evaluation does not require prior authorization

CHIP CHIP PERINATE STAR
Chiropracter *
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Mental Health Rehabiliation/Targeted Case Management
NOT COVERED

NOT COVERED

Needs Prior Authorization
Podiatry In-Office Surgical (excluding CPT codes 11720, 11721, 11730, 11732, and 11750)
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
Evaluation
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
Procedures
Needs Prior Authorization

NOT COVERED

Needs Prior Authorization
CHIP CHIP PERINATE STAR
Air Transport
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Non-emergent ambulance
Needs Prior Authorization

Needs Prior Authorization

Needs Prior Authorization
Emergency Medical Transportation does not require prior authorization
Does not need Prior Authorization

Does not need Prior Authorization

Does not need Prior Authorization