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Biomarker Testing Noncovered Services Language to Be Updated in TMPPM

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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 January 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM), Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 5.2.3, “Biomarker Testing,” to add language for noncovered services.

The following language will be added under noncovered services:

Biomarker testing that does not predominately address the acute or chronic issue for which the test is being ordered.

Note: A covered biomarker test that predominately addresses the acute or chronic issue for which the test is being ordered may include some information that cannot be immediately used in the formulation of a clinical decision.

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