Subject: Unclassified Medical Drugs Prior Authorization Requirement

Date: May 8, 2023

Attention: All Providers

Effective Date: June 8, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective June 8 2023, medical claims under $5,000 submitted to TCHP with unclassified Healthcare Common Procedure Coding System (HCPCS) code J3490 will no longer require a pre-service (prior authorization) request as claims above this cost will be subject to clinical necessity review by the pharmacy team.

This dollar limit does not apply to other unclassified codes J9999, J3590, or C9399. Any claim for these codes are subject to a clinical pre-service review for payment. Please see the latest prior authorization list for a comprehensive list of medical drugs and services requiring pre-service review.

Please note: J7199 has not been a Texas Medicaid payable benefit since March 1, 2023. The bulletin announcement can be found here on the TMHP website.

How this impacts providers: Providers, offices, or other medical facilities wishing to submit medical drug claims that are $5,000 (USD) or more to TCHP with HCPCS code J3490 will need to submit a pre-service (prior authorization) request. Each request will be subject to a clinical necessity review. Clinical appropriateness will be determined by assessing various resources, including but not limited to: U.S. Food and Drug Administration (FDA) package insert, clinical trials, primary, secondary, and tertiary literature, drug’s indicated use, approved patient population, inclusion/exclusion criteria, among other factors.

As a reminder, all medical drug claims must have the appropriate HCPCS and National Drug Code (NDC) combination, unit of measure, and date of service per the latest Medicaid crosswalk. The crosswalk is updated quarterly and can be downloaded from the Vendor Drug Program website under Resources > Downloads. The website also contains a formulary search tool for medical drugs.

Next steps for providers: The Center for Medicare and Medicaid (CMS) produces HCPCS codes. Many older and commonly used drugs may still have unclassified codes. Providers and offices should work closely with their procurement and billing personnel to understand how much the drug costs to purchase to administer in the outpatient setting prior to administering and billing.

Resources

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

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.