Reimbursement Update for Procedure Codes Pending a Rate Hearing

Date: February 14, 2023 

Attention: All Providers

Effective date: May 8, 2023

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Beginning May 8, 2023, TCHP will follow the Texas Medicaid Provider Procedures Manual (TMPPM) guidance regarding claims and the procedure codes that are pending a rate hearing.This provider alert is intended to provide 90 days’ advance notice of this change to providers. By following TMPPM policy, beginning May 8, 2023, TCHP will deny these claims until the reimbursement rates for the applicable procedure codes are adopted. Until then, TCHP will continue to pay these codes at a percent of the vendor contracted rate.

Sources: 

SECTION 6: PROCEDURECODING, Subsection 6.3 Rate Hearings for New HCPCS Codes

SECTION 5: FEE-FOR-SERVICE PRIOR AUTHORIZATIONS, Subsection 5.11 Guidelines for Procedure Awaiting Rate Hearing 

How this impacts providers: Once the reimbursement rates are established, TCHP will adjust the affected claims and pay accordingly. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Next steps for providers: Providers should share this communication with their staff.

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

For access to all provider alerts,log into:

www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.