Maintenance Dialysis Benefits for Texas Medicaid Change

Date: May 20 2024

Attention: All Providers

Effective Date: March 1, 2024

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after March 1, 2024, maintenance dialysis benefits changed for Texas Medicaid. 

Maintenance Hemodialysis, IPD, CCPD, and CAPD

The number of peritoneal dialysis treatments for continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) in the home is limited to 14 sessions within 31 days. This limit is set regardless of the number of dialysate exchanges that are performed per day. Any treatment combination of hemodialysis, intermittent peritoneal dialysis (IPD), CAPD, or CCPD is also limited to 14 sessions within 31 days for any provider.

If more than 14 sessions are required, the provider must submit documentation of medical necessity with the claim. Documentation can include but is not limited to medical records, physician notes, and lab results.

The ordering physician must maintain documentation supporting medical necessity in the client’s medical record, including the documentation for any extra sessions that are required.

Providers can review prior authorization criteria and additional information in the current Texas Medicaid Provider Procedures Manual (TMPPM), Clinics and Other Outpatient Facility Services Handbook, Section 6.2.2, “Renal Dialysis Facilities – Consolidated Billing,” on April 1, 2024, to reflect the above benefit information.

Next step for Providers: Providers are encouraged to 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.