The Long-Term Care (LTC) Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waiver Programs Provider User Guide received updates to reflect new changes implemented on the LTC Online Portal (LTCOP) of the Texas Medicaid & Healthcare Partnership (TMHP). Enhanced accuracy together with increased efficiency, represent the main goals of the recent system updates for form submission and Medicaid eligibility tracking functions.
Key Updates:
Form Submission Sequencing
Long-Term Care Online Portal now prevents Local Intellectual and Developmental Disability Authorities from sending Individual Plan of Care enrollments unless they obtain an approved 8578 Intellectual Disability/Related Condition Purpose Code of 2 indicating No Current Assessment through the approval process. Any LIDDA needs to wait until the 8578 ID/RC PC 2 No Current Assessment reaches the “Pending IPC Match” status before submitting an enrollment IPC. The requirement ensures correct submission order between different systems, hence decreasing errors during processing.
Medicaid Eligibility Reports
The LTCOP updated its Medicaid eligibility reports by renaming them and applying enhancements, which increased clarity along with efficiency standards. Medicaid Eligibility Due in 90 Days has been reformatted as Medicaid Annual Renewal Due Within 1 Year, and Lost/Losing Medicaid by End of Month took the place of the former Medicaid Eligibility report. The new version of eligibility reports includes the display of Medicaid Recertification Dates. The recent system updates seek to simplify reporting tasks for providers and LIDDAs to avoid Medicaid expirations, which might stem from missed annual renewals.
Accessing the Updated User Guides
Users can access the updated provider user guides through the TMHP 1915c Waiver Programs Reference Material web page under the “User Guides” section. Access to the provider user guides is possible through TMHP’s Learning Management System, which can be accessed by logged-in or newly registered users. The Learning Management System requires either an existing account login or new account registration by providers. The user guides are available for online viewing and can also be obtained for offline use.
Access problems with the LMS should be reported to TMHP LMS support through an email directed at TMHPTrainingSupport@tmhp.com. For additional assistance, contact the TMHP LTC Help Desk through the number 800-626-4117 option 1.
The Texas Medicaid & Healthcare Partnership (TMHP) initiated a vital adjustment to Texas Medicaid Provider Procedures Manual (TMPPM) sections detailing Oral Evaluation and Fluoride Varnish (OEFV) operations in medical home facilities. These new guidelines starting April 1, 2025 bring enhanced requirements clarity to healthcare providers delivering the offered services.
The Texas Medicaid & Healthcare Partnership (TMHP) detailed that this change directly affects subsection 4.3.13.1 within the Children’s Services Handbook of the TMPPM. Under the new guidelines:
Healthcare providers associated with Texas Health Steps medical checkups need to finish the required benefit education while maintaining Texas Health Steps Dental certification for providing OEFV services.
The primary care provider (PCP) must conduct the intermediate oral evaluation, although they can delegate the execution of all other OEFV service components.
Through this update, Texas Medicaid-managed care organizations (MCOs) receive a reminder that they need to deliver every medically necessary Medicaid-covered service to the members who enroll. Medical care organizations (MCOs) implement different administrative procedures than traditional Medicaid fee-for-service programs, which include prior authorization, precertification, referrals, and encounter and claims data submission. Each provider must get the exact compliance requirements from the MCO that serves the member.
Additional information about these updates can be provided through the TMHP Contact Center at 800-925-9126.
The revision process focuses on simplifying medical home oral health services by establishing both provider training requirements and certification qualifications. Each provider giving OEFV must closely examine the modifications to verify Texas Medicaid compliance.
Starting March 1, 2025, the Children with Special Health Care Needs (CSHCN) Services Program will raise its payment rates for specific dental procedure codes that are performed after the listed date. The adjustments will be posted following the public rate hearing conducted on November 12, 2024.
TMHP has declared that these modified rates remain a component of their continuous initiative to improve dental service payment equality under the CSHCN Services Program. The new revisions could affect healthcare organizations that specialize in treating children with special health needs.
Healthcare professionals together with stakeholders can access the official Dental Spreadsheet to review the modified reimbursement rates that show all procedural adjustments. The new payment rates introduce improvements to service accessibility and enhance payments to match modern standards.
To obtain more information, providers should connect with the TMHP-CSHCN Services Program Contact Center at 800-568-2413.
Michigan members of UnitedHealthcare Community Plan must request prior authorization or notification for all specific provider-administered medications that require it. Treatment changes have been deployed to cover a wide variety of therapies because they meet the medical necessity standards.
Affected Medications
The following medications will now require prior authorization:
| NameDrug | HCPCS code |
| Briumvi™ | J2329 |
| Corticotropin® Gel | J0802 |
| Daxxify® | J0589 |
| Eylea™ HD | J0177 |
| Izervay™ | J2782 |
| Leqembi™ | J0174 |
| Panzyga® | J1576 |
| Pombiliti™ | J1203 |
| Qalsody™ | J1304 |
| Rystiggo™ | J9333 |
| Syfovre™ | J2781 |
| Tofidence™ | Q5133 |
| Tzield™ | J9381 |
| Veopoz™ | J9376 |
| Vyjuvek™ | J3401 |
| Vyvgart® Hytrulo™ | J9334 |
How to Submit a Prior Authorization Request
Providers can submit prior authorization requests through the UnitedHealthcare website by following these steps:
Beginning June 2, 2025, UnitedHealthcare Community Plan (Medicaid) will demand electronic methods for submitting claim reconsiderations alongside medical pre- and post-service appeals. The new policy has been enacted for most health care providers and facilities participating in network services serving Medicaid members across Florida, New York, Ohio, and Rhode Island.
Patients who work with revenue cycle management companies as external providers need to provide their vendors with knowledge about amended digital workflow standards.
Pre-Service Appeal Submission Process
Before starting with pre-service appeals, Healthcare providers need to use the Prior Authorization and Notification function from the UnitedHealthcare Provider Portal.
Claim Reconsiderations and Post-Service Appeals
Providers may choose between two methods to file claim reconsiderations and post-service appeals:
1. UnitedHealthcare Provider Portal
2. Application Programming Interface (API)
The Provider Portal enables providers to reach 24/7 chat assistance while UnitedHealthcare Web Support can be reached at 866-842-3278 (select option 1) from 7 a.m.– 9 p.m. CT during Monday through Friday.
Beginning April 1, 2025, UnitedHealthcare will eliminate the need for prior authorization and concurrent review procedures for home health services managed by Home & Community, including naviHealth in their system. The insurer continues its organizational-wide strategy to lower prior authorization volume by 10% through this policy change while enhancing healthcare delivery for members and providers.
The updated policy from UnitedHealthcare will affect both Medicare Advantage and Dual Special Needs Plans (D-SNP) within the states as well as Washington, D.C. However, in Florida and Tennessee, existing requirements for D-SNP plans not managed by Home & Community will remain in effect.
Key Takeaways for Providers
Background
The changes in regulation fit within UnitedHealthcare’s ongoing efforts to improve prior authorization methods. The insurer has eliminated prior authorization demands for procedures responsible for 20% of its total healthcare services during 2023. The Gold Card program from UnitedHealthcare originated in 2024 to offer qualifying providers automatic authorization exceptions for specific healthcare services at the national level.
Contact Information
For additional details about the policy, providers should contact their provider advocate or access information at the UnitedHealthcare Contact Us webpage.
UnitedHealthcare Community Plan of Missouri established a new verification process for providers who need to check Coordination of Benefits (COB) details before starting a formal appeal procedure. The program has been established to simplify claim processing and minimize delays caused by COB errors.
Denied COB reconsideration request, providers can verify COB information through direct email communication to mo_cns_operations_escalations@uhc.com before starting their appeal process. The email requires providers to supply essential member information, including name and ID number, along with date of service, reconsideration reason with reference number, and any supporting evidence.
Verifying COB through the Provider Portal
Users may confirm patient COB details through the UnitedHealthcare Provider Portal by performing these steps:
COB Training for Providers
UnitedHealthcare delivers an exclusive COB training program for provider understanding of COB process requirements. Providers who need information about COB can find it through two main ways. First they should go to the Policies Information Features menu, or secondly search for "Coordination of Benefits."
Support and Assistance
The UnitedHealthcare Provider Portal features a 24/7 chat option that providers can use for gaining additional assistance. The Contact Us page contains extra details for customers to access.
UHCprovider.com gives the most recent information about provider guidelines and policy updates.
New Benefits Introduced to Enhance Oral Health Education and Accessibility
Starting March 1, 2025, Texas Health Steps will implement significant changes to its dental services, expanding benefits to include oral health education, teledentistry services, and separate reimbursements for First Dental Home (FDH) visits. The update aims to enhance oral health accessibility and education for children and young clients across Texas.
Key Updates to Dental Benefits
1. Introduction of New Dental Procedure Codes
Procedure Code D9994 – Now covers patient education to improve oral health literacy, reimbursable for clients aged 6 to 35 months to federally health centers (FQHC), Texas Health steps dental, and local health department providers for in-office service.
Procedure Code D9995 – Used to indicate that a dental service was performed via teledentistry and must be billed with:
Reimbursement for these services is available to Federally Qualified Health Centers (FQHCs), Texas Health Steps dental providers, oral maxillofacial surgeons, and local health departments when services are provided in an office setting.
2. First Dental Home (FDH) Program Enhancements
The FDH program, which ensures that young children have an established "dental home," now allows for separate reimbursement of additional services when provided during an FDH visit. These include but are not limited to:
Restrictions on Frequency
Teledentistry is now an officially recognized benefit under Texas Medicaid. Providers must adhere to the Texas Dental Practice Act and regulations set by the Texas Board of Dental Examiners (TSBDE).
Teledentistry Guidelines & Billing
Synchronous (Real-Time) Teledentistry Requirements
D9995 (Real-Time Encounter Indicator) must be included on the claim form.
Additional documentation in the dental record is required, including:
Eligibility for Teledentistry Services
Periodic Oral Evaluation (D0120) – Available via teledentistry for clients aged 3 to 20 years, provided that:
Limited Problem-Focused Oral Evaluation (D0140) – Available via teledentistry for clients from birth through 20 years, provided that:
Reimbursement & Denials
Next Steps for Providers
Providers offering services under Texas Health Steps should update their billing practices and review the benefit criteria with their Medicaid Managed Care Organization (MCO) for specific authorization and reimbursement policies.
For more details, visit TMHP News or contact the TMHP Contact Center at 800-925-9126.
As of April 1, 2025, UnitedHealthcare will not require prior authorizations for Cell-Free Fetal DNA Testing under its commercial plans, community plans, and individual exchange plans in the United States.
Reason for the change
The healthcare experience simplification initiative represents a broad-based strategy to benefit members and network healthcare professionals. These services will not require prior authorizations starting April 1, 2025, but reimbursement depends on the proper medical necessity of the tests according to medical policy guidelines.
Affected procedures
The following procedures fall under the scope of this change:
Affected plans
This change affects the following plans:
Provider Services maintains a contact number on member health care ID cards, which providers can use to ask questions about this NIPT prior authorization policy change. Healthcare professionals must consult the full medical policy containing complete coverage criteria and documentation needs for non-invasive prenatal testing.
UnitedHealthcare maintains its dedication to burdensome process reduction by implementing an efficient process for NIPT service oversight. UnitedHealthcare maintains a strong partnership with providers to provide excellent prenatal care services to members.
Texas Healthcare providers must send their required clinical documentation in due time for all pharmacy-prior authorizations under Texas Medicaid. UnitedHealthcare reports that incomplete submissions of prior authorization documentation create delays or denials which affects patient medicine accessibility.
All prior authorization requests for pharmacy need clinical documentation to prove both medical necessity and procedural requirements. Submitting supporting documents acts as the requirement for successful pharmacy prior authorization requests. Pharmacy prior authorization gets processed within 24 hours whenever medical necessity needs immediate review.
Acceptable clinical documents for UnitedHealthcare pharmacy coverage follow provider policies together with input from physicians and pharmacist specialists who determine coverage validity. Additionally, the Texas Health and Human Services Commission (HHSC) sets certain documentation requirements.
Medical record submission for drugs such as Humira includes a set of detailed specifications that providers need to furnish.
UnitedHealthcare Provider Portal lets providers request prior authorizations through UHCprovider.com by accessing the “Specialty Pharmacy” section under the submission steps. Other submission methods include:
UnitedHealthcare provides 24/7 provider support through its Provider Portal chat feature. Users can find the Clinical Prior Authorization Guidelines together with additional details at UnitedHealthcare's website.
