List of Services Requiring Prior Authorization

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Clinician Administered Drugs

Service

Biologicals over $500 administered in office or outpatient setting

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Biosimilars over $500 administered in office or outpatient setting

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Chemotherapy over $500 administered in office or outpatientsetting

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Gene Therapy

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Hydroxyprogesterone
(17-P)

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Injectable immunoglobulins over $500 administered in office or outpatient setting

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Injectable intravitreal (eye) medications over $500 administered in office or outpatient setting

CHIP

Needs Prior
Authorization

CHIP PERINATE

Does not need
Prior Authorization

STAR

Needs Prior
Authorization

Makena over $500 administered in office or outpatient setting

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

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Dental Procedures

Service

Dental Anesthesia (deep sedation or general anesthesia for dental procedures for children six years of age or younger)

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

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Durable Medical Equipment (DME)/Supplies

Service

DME greater than
$300/item

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

DME or supplies in excess of benefit limitations (see TMHP Provider Procedures Manual)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

DME rentals longer than two months

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Enteral formulas and nutritional supplies/supplements

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Orthotics
(over $200/item)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Prosthetics
(over $200/item)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Home Health Services

*Initial evaluation does not require prior authorization

Service

Private Duty Nursing *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Skilled Nursing require *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Imaging / Radiology / Diagnostic

Service

CT Scan

CHIP

Does not need
Prior Authorization

CHIP PERINATE

Does not need
Prior Authorization

STAR

Does not need
Prior Authorization

Fetal Echocardiography only the following codes (76825, 76826, 76827, 76828)

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

MRI

Does not need
Prior Authorization

PET Scan require a prior authorization

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Sleep Studies require a prior authorization

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Outpatient Hospital

Service

Ambulatory Surgical Center Procedures

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Chemotherapy

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Dialysis

Needs Prior
Authorization

NOT COVERED

Needs Prior
Authorization

Heart Cath procedures

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Intensive Outpatient Hospitalization

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Partial Hospitalization Program

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Prescribed Pediatric Extended Care Center (PPECC)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Heart Cath procedures

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Intensive Outpatient Hospitalization

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Inpatient Hospitalization

*Notification of inpatient admission is required within one business day after admission

Service

Deliveries extending beyond 2 days after vaginal/3 days after caesarean section

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Deliveries-Routine do not require a prior authorization

Does not need
Prior Authorization

Elective/Scheduled procedures *

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Emergent Medical admission do not require a prior authorization *

Does not need
Prior Authorization

Emergent Psychiatric admission do not require a prior authorization *

Does not need
Prior Authorization

NOT COVERED

Does not need
Prior Authorization

Inpatient hospice *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Nursery stay in which newborn remains inpatient after mother is discharged

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Rehabilitative *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Substance Abuse Treatment *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Outpatient Surgical Centers

Service

Elective procedures

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Scheduled procedures

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

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Other Medical Services

Service

Allergy injections when limits are exceeding (see Texas Medicaid Provider Procedures Manual for limitations)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

BRCA screening
(excluding cpt 82105)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Emergency Room Care does not require prior authorization

Does not need
Prior Authorization

Family Planning does not require prior authorization (contraceptive drugs/devices
are not a benefit for CHIP

Does not need
Prior Authorization

NOT COVERED

Does not need
Prior Authorization

Genetic testing

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Hearing Aids

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Implantable Devices

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Primary Care Physician office visit do not require prior authorization

Does not need
Prior Authorization

Specialist-to-Specialist Referral

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Transfers – non-emergent facility to facility outside of El Paso service area

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Venous Procedures (in-office/outpatient)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Out-of-Network

Service

All out-of-network medical
and behavioral services
(except emergent) require
a prior authorization

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

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Rehabilitative Services

*Initial evaluation does not require prior authorization

Service

Occupational Therapy (OT) *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Physical Therapy (PT) *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Speech Therapy (ST) *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Re-evaluation for
OT, PT, and ST

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Specialist

*Initial evaluation does not require prior authorization

Service

Chiropracter *

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Mental Health Rehabilitation/Targeted Case Management

CHIP

NOT COVERED

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Podiatry In-Office Surgical (excluding CPT codes 11720, 11721, 11730, 11732, and 11750)

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Transplant Services

Service

Evaluation

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

Needs Prior Authorization

CHIP

Needs Prior
Authorization

CHIP PERINATE

NOT COVERED

STAR

Needs Prior
Authorization

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Transportation

Service

Air Transport

CHIP

Needs Prior
Authorization

CHIP PERINATE

Needs Prior
Authorization

STAR

Needs Prior
Authorization

Non-emergent ambulance

Needs Prior
Authorization

Emergency Medical Transportation does not require prior authorization

Does not need
Prior Authorization