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Effective September 1, 2025, Benefit Limitations for Colony-Stimulating Factors Will Change

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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.

Texas Medicaid will change some benefit limitations for colony-stimulating factors, effective for dates of service on or after September 1, 2025.

The following colony-stimulating factor procedure codes will no longer be diagnosis-restricted:

Procedure Codes
J1442J1447J1449J2506J2820Q5101Q5108
Q5110Q5111Q5120Q5122Q5125Q5127Q5130

Billing Guidelines

Texas Medicaid will deny claims for the reimbursement of the following procedure codes when the same provider submits a claim for specific procedure codes with the same date of service:

Procedure CodeDenied If Billed WithWhen Submitted
J1442J1449, J2506, or J2820By the same provider on the same date of service
J1449J1442, J2506, or J2820.By the same provider on the same date of service
J2506J1442, J1449, or J2820By the same provider on the same date of service
1-J2820J1442, J1449, or J2506.By the same provider on the same date of service

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