Texaschildrenshealthplan Prior Authorization Lookup
Latest Texaschildrenshealthplan prior authorization updates24
- Prior AuthClinical/Medical PolicyEff. 2026-04-20Circumcision Authorization and Medical NecessityThis guideline governs authorization and medical-necessity review for circumcision requested for Texas Children's Health Plan members. Prior authorization is not required for children younger than 1 year; requests for members aged 1 year and older require supporting documentation and utilization-management review.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-20Day Activity and Health Services (DAHS) GuidelineGoverns prior authorization and service requirements for DAHS for Texas Children's Health Plan STAR Kids members age 18 and older with chronic medical conditions who may benefit therapeutically; applies to DAHS providers, facilities, nurses, physicians, and utilization management reviewers.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-20Nutritional Supplements GuidelinesThis guideline governs coverage, prior authorization, medical necessity, documentation, coding, and reimbursement requirements for nutritional products, enteral formulas, related supplies, and selected nutritional equipment for Texas Children's Health Plan members and providers.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-20Physical Occupational and Speech Therapy GuidelineThis guideline governs medical necessity, coverage, prior authorization, documentation, telehealth, and ongoing treatment requirements for physical, occupational, and speech therapy provided to Texas Children's Health Plan members.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-21General Anesthesia for Dental Procedures in Members 6 years old and YoungerPrior authorization and medical-necessity review for general anesthesia and associated facility fees during dental procedures for Texas Children's Health Plan members enrolled in STAR or STAR Kids.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2024-08-29Clinician Administered Drug GuidelineGuideline for prior authorization, medical necessity review, coding, and reimbursement of clinician-administered drugs provided to Texas Children's Health Plan members under the medical benefit.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2024-06-21Outpatient Psychotherapy Visits Greater than 30 per Calendar YearThis guideline governs prior authorization for additional individual, group, or family outpatient psychotherapy visits after a member reaches the annual limit of 30 visits. It applies to providers serving Texas Children's Health Plan members.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-21Monoclonal Antibodies for Asthma and Allergic Conditions GuidelineThis guideline governs Texas Children's Health Plan prior authorization for selected monoclonal antibody therapies used for asthma, chronic idiopathic urticaria, eosinophilic disorders, and chronic rhinosinusitis with nasal polyps. It applies to providers requesting these injectable therapies for TCHP members and specifies initial-therapy, continuation, documentation, and medical-necessity requirements.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-21Wheelchairs and Associated Mobility AccessoriesThis guideline governs prior authorization and medical-necessity review for wheelchairs, wheeled mobility systems, scooters, medical strollers, repairs, and associated accessories for Texas Children's Health Plan members.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-07Gait Trainers and Standers GuidelinesThis guideline governs prior authorization, documentation, medical necessity, coding, replacement, and review requirements for pediatric gait trainers, standers, and related accessories for Texas Children's Health Plan members.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2024-02-29Therapeutic and Reconstructive Breast Procedures GuidelineThis guideline governs prior authorization and medical-necessity review for surgical breast procedures, breast reconstruction, breast reduction, mastectomy, gynecomastia surgery, and breast prostheses for Texas Children's Health Plan members.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-08-31Orthoses GuidelineThis guideline governs prior authorization, medical necessity, provider qualifications, documentation, reimbursement, and exclusions for orthoses and related services for Texas Children's Health Plan members under Texas Medicaid requirements.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-08-31Secretion and Mucous Clearance Devices GuidelineThis guideline governs Texas Children's Health Plan authorization and medical-necessity review for secretion and mucous clearance devices, including cough augmentation, HFCWO, IPV, electrical percussors, and IPPB devices. It also identifies devices that do not require prior authorization and establishes rental, purchase, replacement, and recertification requirements.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-08-31Single Photon Emission Computed Tomography (SPECT) Scan GuidelinesThis guideline governs prior authorization and medical-necessity review for all SPECT scans requested for Texas Children's Health Plan members. It identifies required submission documentation, covered clinical indications, and non-covered or experimental/investigational uses.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-06-27Maternal Magnetic Resonance Imaging (MRI)Coverage and prior authorization requirements for fetal, placental, and maternal pelvic MRI for pregnant Texas Children's Health Plan members.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-06-27Noninvasive Prenatal Screening (NIPS or NIPT) Genetic Testing GuidelinesPrior authorization and medical-necessity review for noninvasive prenatal screening during pregnancy, including eligibility, documentation, coverage limitations, and non-covered uses.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-02-22Cranial Molding Orthosis GuidelinesThis guideline governs prior authorization and medical-necessity review for cranial molding orthosis devices requested for Texas Children's Health Plan members. It defines covered indications, non-covered indications, documentation requirements, and lifetime device limitations.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2023-01-23Bariatric Surgery Authorization and Medical NecessityThis guideline governs prior authorization and medical necessity review for bariatric surgery requested for Texas Children's Health Plan members. It establishes required clinical documentation, facility standards, contraindications, repeat-surgery criteria, and exclusions.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2022-11-18Prescribed Pediatric Extended Care Center (PPECC)Prior authorization, medical necessity, documentation, service limits, continued authorization, revisions, provider changes, and termination or denial of PPECC services for eligible Texas Children's Health Plan Medicaid members in Texas.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2022-11-16Durable Medical Equipment (DME) Service ProcedureGoverns access, benefit limitations, prior authorization, provider choice, and medical-necessity review for durable medical equipment and supplies for Texas Children's Health Plan members across STAR, STAR Kids, CHIP, and other applicable lines of business.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-08Miscellaneous Durable Medical Equipment (DME) When Billed Amount Exceeds $500Guideline for prior authorization and medical-necessity review of miscellaneous durable medical equipment billed with E1399, A9900, or T1999 when charges exceed $500 for Texas providers and members.All texaschildrenshealthplan updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-09-07Utilization Management COVID-19 ProcedureTemporary 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.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2021-07-1917 alpha-hydroxyprogesterone caproate Therapy GuidelinesThis guideline governs prior authorization and medical-necessity review for 17 alpha-hydroxyprogesterone caproate therapy intended to prevent recurrent preterm delivery for Texas Children's Health Plan members. It specifies required submission documentation, eligible pregnancy and treatment criteria, dosing limits, and denial conditions.All texaschildrenshealthplan updates
- Prior AuthClinical/Medical PolicyEff. 2020-02-20Skills Training Request for CHIP MembersThis guideline governs prior authorization and medical-necessity review for skills training requested for Texas Children's Health Plan CHIP members. Targeted Case Management is not a CHIP benefit.All texaschildrenshealthplan updates
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Tool Description
Search Texaschildrenshealthplanprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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