Sleep Studies no longer require Prior Authorization

Date: March 22, 2024
 
Attention: All Providers
 
Effective date: February 7, 2024

Call to action: Effective for dates of service on or after February 7, 2024, Texas Children’s Health Plan (TCHP) will not require a prior authorization for sleep studies.

Disclaimer: It is the responsibility of the Provider to verify that a service is a benefit of Texas Medicaid for service codes that TCHP does not require prior authorization. Services rendered by out-of-network providers will require prior authorization.

TCHP would like to remind providers that they can submit Prior Authorizations securely online via Texas Children’s® Link, our online provider portal. Providers are encouraged to submit authorization requests on our portal since this is the most efficient way for our team to process authorizations. To access Texas Children’s® Link, click here.

Additionally, Texas Children’s Health Plan (TCHP) supports the guidance from Texas Health and Human Services Commission (HHSC) on rejecting the Prior Authorization (PA) received with incomplete or insufficient documentation per Uniform Managed Care Manual (UMCM), Chapter 3.22. Therefore, PA requests submitted without Essential Information will be rejected until the correct information is provided.

Sleep Study procedure codes no longer requiring prior authorization:

Pneumocardiogram:  95807

Multiple Sleep Latency Test (MSLT):  95805

Polysomnography:  95782, 95783, 95808, 95810 and 95811

Please refer to the Texas Medicaid Provider Procedure Manual for limitations and applicable diagnosis codes. All other diagnosis codes will require prior authorization.

Next step for Providers: Providers should follow the prior authorization guidelines as stated above, follow the applicable diagnosis codes information available in TMPPM, and 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.