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 January 1, 2020, antisense oligonucleotides (eteplirsen and nusinersen) benefits will change for Texas Medicaid.
Procedure codes J1428 and J2326 will no longer have age limitations, and prior authorization requests will be considered for clients of any age.
Claims with dates of service on or after January 1, 2020 that were denied for client age, will be reprocessed and may result in an additional payment, which will be reflected on future Remittance and Status (R&S) Reports.
For more information, call the TMHP Contact Center at 800-925-9126.