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Prior Authorization Criteria for Hormonal Therapy Agents Effective March 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On March 1, 2024, the Texas Health and Human Services Commission (HHSC) will add prior authorization criteria for the following hormonal therapy agents procedure codes:

Procedure Codes
J1000J1071J1380J1950J1951J3121
J3145J3315J3316J9155J9217J9218
J9226S0189    

Reimbursement of Claims

After the implementation of new criteria for the above procedure codes, claims will not be reimbursed when submitted with the following International Classification of Diseases Tenth Revision (ICD-10) codes:

ICD-10 Codes
F640F641F642F648F649 

Note: HHSC will publish a policy update to the Texas Medicaid Provider Procedures Manual (TMPPM) to align with recent state law changes and post the proposed policy updates for public comment. This standard process will occur before the implementation of the update.

For more information, call the TMHP Contact Center at 800-925-9126.

For questions about outpatient CAD, email vdp-cad@hhsc.state.tx.us.

For questions about medical benefits, email MedicaidBenefitRequest@hhsc.state.tx.us.