Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 October 1, 2022, Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook.
Removal of Some Procedure Codes and Duplicate Sections
Ontak (procedure code J9160) was discontinued, and section 6.26, “Denileukin diftitox (Ontak),” will be removed.
Ibutilde fumarate (procedure code J1742) will no longer be diagnosis-restricted and section 6.46, “Ibutilide fumarate,” will be removed.
Procedure codes J1458 and J1743 are listed in more than one section of the Outpatient Drug Services Handbook, so the following duplicate sections will be removed: section 6.38, “Galsulfase,” and section 6.47, “Idursulfase (Elaprase).”
Diagnosis Code Restriction Updates
Diagnosis code restrictions will be updated for Melphalan (procedure code J9245) and Melphalan (Evomela) (procedure code J9246) in section 6.8.12, “Melphalan (Evomela).” Procedure codes J9245 and J9246 will be restricted to diagnosis codes C9000, C9001, and C9002.
Age Restriction Update
Melphalan (Evomela) procedure code J9246 will no longer be age-restricted.
For more information, call the TMHP Contact Center at 800-925-9126.