Skip to main content

Reimbursement Rate Updates for Certain HCPCS Drug Procedure Codes Effective April 1, 2025

Last updated on

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.

Effective for dates of service on or after April 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will change the reimbursement rates for certain Healthcare Common Procedure Coding System (HCPCS) drug procedure codes that were updated during the first quarter of 2025. These rate updates will be implemented for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program.

TMHP will reprocess any affected claims that are identified. Providers can appeal the claims if TMHP denies them for additional reasons after reprocessing is completed.

To view the updates, access the Drug Procedure Codes spreadsheet.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.