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 |
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 |
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) | Does not need Prior Authorization | 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 |
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 |
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 |