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.
On September 29, 2020, TMHP will implement the third quarter 2020 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2020.
Third Quarter 2020 HCPCS Added Procedure Codes
Click to view the Clinician Administered Drug (CAD) Procedure Codes. Procedure codes noted with an asterisk in the table linked above will not require a rate hearing.
Reminder: The clinician administered drug procedure codes listed in the table above will be added as Medicaid benefits as of the Centers for Medicare & Medicaid Services (CMS) effective date, October 1, 2020. Claims will deny until a rate is implemented, but affected claims will be reprocessed back to the CMS effective date. The procedure codes will be payable at the October 1, 2020, published rate until the HHSC rate hearing is held, as required by the Texas Administrative Code 355.201.
Providers may also refer to the following website for details related to rate hearings: https://rad.hhs.texas.gov/rate-packets
The procedure codes in this table will be a benefit for clients who are 18 years of age and older:
Prior Authorization Requirements
Procedure code J1632 is a replacement for discontinued procedure code C9055, and will have the same prior authorization requirements.
Refer to: The current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.12, “Brexanolone (Zulresso),” for the prior authorization requirements.
Procedure code J3241 is a replacement for discontinued procedure code C9061, and will have the same prior authorization requirements.
Refer to: The article titled, "Teprotumumab-trbw (Tepezza), a Benefit of Texas Medicaid, Will Require Prior Authorization Effective October 1, 2020," which was published on this website August 14, 2020,” for the prior authorization requirements for procedure code J3241.
Third Quarter 2020 HCPCS Discontinued Procedure Codes
Effective October 1, 2020, CMS will discontinue the following procedure codes listed in this table.
Discontinued procedure codes will not be reimbursed after September 30, 2020.
Third Quarter 2020 HCPCS Revised Procedure Codes
The description of the procedure codes listed in this table will be revised.
Third Quarter 2020 HCPCS Informational Procedure Codes
The following procedure codes listed in this table will be added as informational only.
Click to view this table listing Third Quarter 2020 HCPCS Modifier Updates.
For more information, call the TMHP Contact Center at 800-925-9126.