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CSHCN Physician Evaluation and Management Office and Outpatient Services Limitation Language Added

Last updated on 3/27/2020

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after May 1, 2020, office and outpatient services limitation language will be added to the Physician Evaluation and Management Services medical policy for the Children with Special Health Care Needs (CSHCN) Services Program.

Office or outpatient consultations will be limited to one consultation every six-month period by the same provider for the same diagnosis. Subsequent office or outpatient consultation visits during this time period will be denied.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.