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Updates to Prior Authorization for Services and Clinician-Administered Drug Benefits for HTW/HTW Plus

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Effective for dates of service on or after July 1, 2026, Texas Medicaid will update prior authorization criteria and clinician-administered drug (CAD) benefits for the Healthy Texas Women (HTW) program.

Prior Authorization for HTW Services

Prior authorization will be required for the following HTW services:

  • Magnetic resonance imagining (MRI) (procedure codes 77046, 77047, 77048, and 77049)
  • Non-prescription glucose tablets or gel (procedure code A9150)

Medical nutritional counseling services do not require prior authorization for HTW clients up to the following quantities:

  • Procedure code 97802: 4 units per rolling year
  • Procedure code 97803: 12 units per rolling year
  • Procedure code 97804: 8 units per rolling year
  • Procedure code S9470: 1 visit per rolling year

Prior Authorization for HTW Plus Services

Prior authorization will be required for the following HTW Plus services:

  • Computed tomographic angiography (procedure codes 70498, 71275, 73706, 74174, 74175, 75574, and 75635)
  • MRI (procedure codes 70547 and 70548)
  • Computed tomography (procedure code 75571)
  • Blood glucose monitors with an integrated voice synthesizer (procedure code E2100)

Blood glucose test or reagent strips (procedure code A4253) do not require prior authorization up to the following quantities:

  • Non-insulin dependent: 1 box per month
  • Insulin dependent: 2 boxes per month

Peer specialist services (procedure code H0038) do not require prior authorization for the first 104 units in a rolling six-month period. Providers must request prior authorization once a client exceeds 104 units of individual or group peer specialist services in a six-month rolling period.

For additional prior authorization requirements and appropriate prior authorization forms, providers can refer to the following handbooks of the current Texas Medicaid Provider Procedures Manual (TMPPM):

  • Behavioral Health and Case Management Services Handbook, section 6.1, “Services, Benefits, Limitations, and Prior Authorization”
  • Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, section 2.2.12.3, “Glucose Testing Equipment and Other Supplies”
  • Radiology and Laboratory Services Handbook, section 4.2.2.5, “Authorization Requirements and Flexibility”

Provider Type Update

Texas Medicaid may reimburse claims for the following procedure codes to rural emergency hospital providers when they render services in the outpatient hospital setting:

Procedure Codes
8658086592866898670193000930159301793041  

CADs

The following CAD procedure codes will be benefits of HTW, and Texas Medicaid may reimburse claims for these codes to family planning clinic, physician assistant, nurse practitioner, clinical nurse specialist, and physician providers when they render services in the office setting and to hospital and rural emergency hospital providers when they render services in the outpatient hospital setting:

Procedure Codes—HTW
J0281J0616J0666J0668J1808J1938J2373S5550  

The following CAD procedure codes will be benefits of HTW Plus, and Texas Medicaid may reimburse claims for these codes to family planning clinic, physician assistant, nurse practitioner, clinical nurse specialist, and physician providers when they render services in the office setting and to hospital and rural emergency hospital providers when they render services in the outpatient hospital setting:

Procedure Codes—HTW Plus
J0702J1010J1100J1437J1439J1643J1644J1645J1650J1652
J1750J1756J2916J2919J3304J3535J7612J8541Q0138 

Texas Medicaid may reimburse claims for the following HTW Plus CAD procedure codes to rural emergency hospital providers when they render services in the outpatient hospital setting:

Procedure Codes—HTW Plus
J1720J3301J7611J7613J7614J7620J7644   

Procedure codes J0695, J1551, J1611, J1729, and J2402 will no longer be HTW benefits.

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

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.