List of Services Requiring Prior Authorization
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Biologicals over $500 administered in office or outpatient setting | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Biosimilars over $500 administered in office or outpatient setting | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Chemotherapy over $500 administered in office or outpatient setting | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Gene therapy | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Hydroxyprogesterone (17-P) | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Injectable immunoglobulins over $500 administered in office or outpatient setting | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Injectable intravitreal (eye) medications over $500 administered in office or outpatient setting | Needs Prior Authorization | COVERED | Needs Prior Authorization |
| Makena over $500 administered in office or outpatient setting | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Dental Anesthesia (deep sedation or general anesthesia for dental procedures for children six years of age or younger) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| DME greater than $300/item | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| DME or supplies in excess of benefit limitations (see TMHP Provider Procedures Manual) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| DME rentals longer than two months | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Enteral formulas and nutritional supplies/supplements | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Orthotics (over $200/item) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Prosthetics (over $200/item) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Private Duty Nursing * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Skilled Nursing require * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| CT scan | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
| Fetal Echocardiography only the following codes (76825, 76826, 76827, 76828) | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| MRI | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
| PET Scan require a prior authorization | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Sleep Studies require a prior authorization | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Ambulatory Surgical Center Procedures | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Chemotherapy | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Dialysis | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Heart Cath procedures | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Intensive Outpatient Hospitalization | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Partial Hospitalization Program | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Prescribed Pediatric Extended Care Center (PPECC) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Residential Treatment Center | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Radiation Therapy | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Wound Clinic Services | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Deliveries extending beyond 2 days after vaginal/3 days after cesarian section | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Deliveries-Routine do not require a prior authorization | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
| Elective/Scheduled procedures * | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Emergent Medical admission do not require a prior authorization * | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
| Emergent Psychiatric admission do not require a prior authorization * | Does not need Prior Authorization | NOT COVERED | Does not need Prior Authorization |
| Inpatient hospice * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Nursery stay in which newborn remains inpatient after mother is discharged | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Rehabilitative * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Substance Abuse Treatment * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Elective procedures | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Scheduled procedures | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Allergy injections when limits are exceeding (see Texas Medicaid Provider Procedures Manual for limitations) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| BRCA screening (excluding cpt 82105) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Emergency Room Care does not require prior authorization | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
| Family Planning does not require prior authorization (contraceptive drugs/devices are not a benefit for CHIP) | Does not need Prior Authorization | NOT COVERED | Does not need Prior Authorization |
| Genetic testing | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Hearing Aids | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Implantable Devices | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Primary Care Physician office visit do not require prior authorization | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
| Specialist-to-Specialist Referral | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Transfers – non-emergent facility to facility outside of El Paso service area | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| Venous Procedures (in-office/outpatient) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| All out-of-network medical and behavioral services (except emergent) require a prior authorization | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Occupational Therapy (OT) * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Physical Therapy (PT) * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Speech Therapy (ST) * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Re-evaluation for OT, PT, and ST | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Chiropracter * | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Mental Health Rehabiliation/Targeted Case Management | NOT COVERED | NOT COVERED | Needs Prior Authorization |
| Podiatry In-Office Surgical (excluding CPT codes 11720, 11721, 11730, 11732, and 11750) | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Evaluation | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| Procedures | Needs Prior Authorization | NOT COVERED | Needs Prior Authorization |
| CHIP | CHIP PERINATE | STAR | |
|---|---|---|---|
| Air Transport | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization | Non-emergent ambulance | Needs Prior Authorization | Needs Prior Authorization | Needs Prior Authorization | Emergency Medical Transportation does not require prior authorization | Does not need Prior Authorization | Does not need Prior Authorization | Does not need Prior Authorization |
Tarjeta de regalo de $25 para Walmart, para miembros menores de 18 años que acudan a una visita de seguimiento con el psiquiatra a más tardar 7 días de estar hospitalizado por un problema de salud mental. Los miembros pueden recibir una tarjeta de regalo al año.
Una tarjeta de regalo de $15 para los miembros de hasta 20 años que acudan a tiempo a un chequeo médico de Pasos Sanos de Texas.
