Durable Medical Equipment Requests Exceeding Benefit Limitations

Date: July 23, 2024

Attention: All Providers

Effective date: September 23, 2024

Call to action: Beginning September 23, 2024, Texas Children’s Health Plan (TCHP) guidelines and prior authorization requirements for Durable Medical Equipment (DME) and medical supplies will change.

This change will align TCHP’s guidelines and prior authorization requirements with Texas Medicaid covered services and benefit limitations as outlined in the Texas Medicaid Provider Procedures Manual (TMPPM).

Starting September 23, 2024, prior authorization requirements for DME and medical supplies are as follows:

• DME and medical supplies listed on TCHP’s prior authorization list
• DME and medical supplies requested in excess of benefit limitations
• Noncovered DME and medical supplies

For dates of service on or after September 23, 2024, TCHP’s published prior authorization list and durable medical equipment guidelines will change as follows:

• TCHP specific limitations will be removed

Verifying Coverage and Limitations:

It is the responsibility of the Provider to verify covered benefits and limitations. Providers must request prior authorization for services as needed for those that are not covered or that exceed benefit limitations.

TCHP reviews requests for noncovered services and services that exceed benefit limitations for medical necessity on a case-by-case basis for members birth to 20 years covered on Texas Medicaid.

Prior authorization resources are available at https://www.texaschildrenshealthplan.org/for-providers/prior-authorization-information by clicking the Prior Authorization Requirements link. These documents are updated periodically so refer to the link regularly.

All services rendered by out-of-network providers require prior authorization. Standard Prior authorization Form

Medical Services Fax Line - 832-825-8760 or Toll-Free 1-844-473-6860.

Next step for Providers: Providers should refer to the Texas Medicaid Provider Procedure Manual for benefit coverage, service limitations and applicable restrictions. 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