CurrentTexas Children's Health PlanPolicy 10594

Utilization Management COVID-19 Procedure

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 10594 alerts

Get alerted when Policy 10594 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Temporary Texas Children's Health Plan utilization management and prior authorization procedures related to the COVID-19 Disaster Declaration, including out-of-network care, therapy, LTSS, private duty nursing, DME, and telehealth services.

Policy Summary

PayerTexas Children's Health Plan

PolicyUtilization Management COVID-19 Procedure

Policy CodePolicy 10594

Change TypeRevised

Effective DateSeptember 7, 2021

Next Review DateN/A

Key ActionSubmit physical, occupational, and speech therapy telehealth services using synchronous audio-visual technology; audio-only visits are not permitted.

SourceLink

POLICY UPDATE CHANGES

Physical therapy delivered by telehealth may be approved for up to 180 days at a time effective September 8, 2021, replacing the 90-day period.

Current Texas Health Steps Checkup documentation is no longer required for speech, physical, and occupational therapy prior authorizations effective June 23, 2021.

Office visit documentation for acute therapy services is required for members over age 21 only effective August 1, 2021.

Providers submitting requests with missing signatures must state "missing signatures, COVID-19" and submit medical necessity documentation.

OON PCPPrior authorization waived

30 days

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentTexas Children's Health PlanPolicy 10594

Utilization Management COVID-19 Procedure

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 10594 alerts

Get alerted when Policy 10594 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerTexas Children's Health Plan

PolicyUtilization Management COVID-19 Procedure

Policy CodePolicy 10594

Change TypeRevised

Effective DateSeptember 7, 2021

Next Review DateN/A

Key ActionSubmit physical, occupational, and speech therapy telehealth services using synchronous audio-visual technology; audio-only visits are not permitted.

SourceLink

POLICY UPDATE CHANGES

Physical therapy delivered by telehealth may be approved for up to 180 days at a time effective September 8, 2021, replacing the 90-day period.

Current Texas Health Steps Checkup documentation is no longer required for speech, physical, and occupational therapy prior authorizations effective June 23, 2021.

Office visit documentation for acute therapy services is required for members over age 21 only effective August 1, 2021.

Providers submitting requests with missing signatures must state "missing signatures, COVID-19" and submit medical necessity documentation.

OON PCPPrior authorization waived

30 days

Standard authorization extension

180 daysPhysical therapy telehealth authorization

7 daysTimely submission window

Audio-visualRequired telehealth format

Medical necessityPreauthorization basis

COVID-19 Utilization Management Criteria

Apply the applicable utilization management criteria below while the COVID-19 Disaster Declaration is in place. Prior authorization is based on medical necessity and does not guarantee benefits or eligibility; all services remain subject to benefit limitations, exclusions, and applicable state and federal requirements.

Prior Authorization Intake and Out-of-Network Services

Prior authorization requests may be submitted to the Utilization Management Department online, by fax, phone, or mail and are processed during normal business hours.
Prior authorization is waived for out-of-network primary care visits provided by pediatricians, family practice/general practice physicians, internal medicine physicians, and obstetricians/gynecologists while the Disaster Declaration is in place.
When an out-of-network primary care service otherwise requires prior authorization, medical necessity criteria and the applicable Utilization Management Guideline apply, including for services such as genetic testing.
An authorization requested by an out-of-network provider for another service may be approved when the member is unable to access an in-network service during the Disaster Declaration.

Existing Authorization Extensions

An extension of an existing authorization may be approved when the provider states that the member was unable to access services during the Disaster Declaration.
Authorization extensions may be issued for 30 days at a time.
Ninety-day authorization extensions follow HHSC-published guidance for Managed Care Organizations.

Provider Changes and Documentation

For therapy, long-term services and supports, private duty nursing, and durable medical equipment, TCHP may waive the change-of-provider letter requirement and approve a change from a previously approved or authorized provider at the provider's or member's request without formal documentation.
Effective December 1, 2020, a change-of-provider letter is required.
When required signatures are missing, the provider must state "missing signatures, COVID-19" in the request.
Effective June 30, 2020, TCHP may waive required timely physician and other provider signatures for processing prior authorization requests.
When timely signatures are waived, providers must state "missing signatures, COVID-19" in the request and must submit medical necessity documentation.

Therapy, Private Duty Nursing, and Texas Health Steps Documentation

Hearing screening and current Texas Health Steps Checkup requirements for speech, physical, and occupational therapy prior authorizations are temporarily waived for services beginning during the Disaster Declaration or for extension requests made during the Disaster Declaration.
Effective August 10, 2020, documentation of an office visit note for an acute injury or acute exacerbation was waived for acute therapy services.
Effective December 1, 2020, documentation of an office visit note for an acute injury or acute exacerbation is required to authorize acute therapy services.
Effective August 1, 2021, documentation of an office visit note for an acute injury or acute exacerbation is required only for members over age 21.
Effective August 10, 2020, the yearly treating-physician office visit requirement was waived for private duty nursing.

Telemedicine and Telehealth

TCHP supports delivery of telemedicine and telehealth services to members.
Telemedicine services must comply with standards established by the applicable licensing or certifying board for the professional providing the services.
Effective March 31, 2020, physical, occupational, and speech therapy may be provided through telehealth during the Disaster Declaration only by synchronous audio-visual format.
Audio-only visits are not permitted for speech, occupational, or physical therapy services.
Speech and occupational therapy delivered by telehealth after a telehealth initial evaluation may be approved for up to 6 months.
Physical therapy delivered by telehealth after a telehealth initial evaluation or face-to-face evaluation may be approved for up to 90 days at a time effective April 3, 2020, and up to 180 days at a time effective September 8, 2021.

Prior Authorization Timing and Benefit Limitations

Effective April 1, 2020, TCHP may accept prior authorization requests submitted within 7 calendar days of the requested service start date, and the request will not be considered retrospective.
Preauthorization is based on medical necessity and is not a guarantee of benefits or eligibility.
Approval applies only to the medical necessity of the treatment or service; all services remain subject to benefit limitations and exclusions.
Providers must comply with state and federal regulatory requirements. Noncompliance may result in retrospective audit and potential financial recoupment.

Authorization Periods and Submission Timing

Standard Authorization Extension

Standard authorization extension30 days at a time

Extension basisMay be issued when the member was unable to access services during the Disaster Declaration

Applicable servicesExisting authorized services, including therapy, LTSS, PDN, and DME

HHSC-Directed Authorization Extension

HHSC-directed extension90 days

Guidance requirementWhen consistent with HHSC published guidance for Managed Care Organizations (MCOs)

Authorization context

Required Provider Actions

Prior Authorization

Submit Prior Authorization Requests

Submit all prior authorization requests to the Utilization Management Department during normal business hours. Requests may be submitted online, by fax, phone, or mail.

Prior Authorization

OON Primary Care Authorization Waiver

Prior authorization is waived for specified out-of-network (OON) primary care visits while the Disaster Declaration is in place.

Applies to OON pediatrician, family practice/general practice, internal medicine, and obstetrics and gynecology visits.
Prior authorization is not required for these services during the Disaster Declaration.

Documentation Required

Key Definitions

Definitions

TermCOVID-19

Illness typeA viral illness

CauseThe novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Definitions

TermDisaster Declaration

DeclarationTexas COVID-19 State of Disaster Declaration

Issue dateMarch 13, 2020

Policy Summary

PayerTexas Children's Health Plan

PolicyUtilization Management COVID-19 Procedure

Policy CodePolicy 10594

Change TypeRevised

Effective DateSeptember 7, 2021

Next Review DateN/A

Key ActionSubmit physical, occupational, and speech therapy telehealth services using synchronous audio-visual technology; audio-only visits are not permitted.

SourceLink

On This Page

Effective March 1, 2021, documentation of a current Texas Health Steps Checkup was required for speech, physical, and occupational therapy prior authorizations through either an ordering-provider attestation or a copy of the current Texas Health Steps Checkup.

A 90-day authorization may be issued for a request missing the current well-child checkup or attestation.

Effective June 23, 2021, documentation of a current Texas Health Steps Checkup is no longer required for speech, physical, and occupational therapy prior authorizations.

Applies to extensions issued during the COVID-19 Disaster Declaration

Speech and Occupational Therapy Telehealth Authorization

ServicesSpeech therapy and occupational therapy delivered by telehealth

Qualifying evaluationAfter a telehealth initial evaluation

Maximum authorization periodUp to 6 months

Physical Therapy Telehealth Authorization

ServicePhysical therapy delivered by telehealth

Qualifying evaluationAfter a telehealth initial evaluation or a face-to-face evaluation

Maximum authorization periodUp to 180 days at a time

Prior Authorization Submission Timing

Submission windowWithin 7 calendar days of the requested service start date

Effective dateApril 1, 2020

Retrospective treatmentThe request will not be considered retrospective

Apply Medical Necessity Criteria When Required

When a service requested by a primary care provider requires prior authorization, apply medical necessity criteria and the applicable Utilization Management Guideline.

Example: genetic testing.

Prior Authorization

Consider OON Services When In-Network Access Is Unavailable

Authorizations requested by OON providers for services not covered by the primary care waiver may be approved when the member is unable to access in-network services during the Disaster Declaration.

Document or address the member's inability to access in-network services before approving the OON service.

Prior Authorization

Extend Existing Authorizations

Approve extensions of existing authorizations when the provider states that the member was unable to access services while the Disaster Declaration was in place.

Authorization extensions may be issued for 30 days at a time.
Ninety-day authorization extensions must follow HHSC-published guidance for Managed Care Organizations (MCOs).

Documentation Required

Process Provider Changes

For therapy, long-term services and supports (LTSS), private duty nursing (PDN), and durable medical equipment (DME), changes to a previously approved or authorized provider may be approved at the provider's or member's request without formal change-of-provider documentation when the waiver applies.

A change-of-provider letter is required effective December 1, 2020.
Apply the applicable effective-date requirements when processing provider changes.

Documentation Required

Document Missing Signatures

When required signatures are missing, providers must state "missing signatures, COVID-19" in the request and submit the required medical necessity documentation.

The missing-signature notation applies to prior authorization request processing under the COVID-19 procedure.
Medical necessity documentation must be submitted.

Documentation Required

Apply Therapy and PDN Documentation Rules

Apply the temporary therapy and PDN documentation waivers and their effective-date requirements for services and extension requests during the Disaster Declaration.

Hearing screening and current Texas Health Steps Checkup requirements for speech, physical, and occupational therapy prior authorizations are temporarily waived for services starting during the Disaster Declaration or for extension requests made during it.
Office visit notes for acute injury or acute exacerbation: waived for acute therapy services effective August 10, 2020; required effective December 1, 2020; effective August 1, 2021, required only for members over age 21.
The yearly treating-physician office visit requirement for PDN was waived effective August 10, 2020.
Current Texas Health Steps Checkup documentation was required for speech, physical, and occupational therapy prior authorizations effective March 1, 2021, through ordering-provider attestation or a copy of the checkup; requests missing the checkup or attestation received 90-day authorizations.
Effective June 23, 2021, current Texas Health Steps Checkup documentation is no longer required for speech, physical, and occupational therapy prior authorizations.

Unsupported block type: billing_rule

Unsupported block type: prior_auth

Unsupported block type: denial_risk