TMHP & HHSC Notices

Prescribing Provider Survey for the Texas Prescription Monitoring Program Due May 11, 2026

The Texas Health and Human Services Commission (HHSC) has created a provider survey that will help in gathering data to report on Texas Prescription Drug Monitoring Program (PDMP) usage by Texas Medicaid-enrolled prescribing providers. The Centers for Medicare & Medicaid Services (CMS) requires states to report data about prescribing providers' use of the Texas PDMP before allowing the providers to prescribe controlled substances.

Provider Revalidation Resource Guide

Provider Revalidation Resource Guide YouTube Videos YouTube videos for step-by-step guidance on completing Medicaid revalidation in PEMS, including how to log in, review and update information, upload documents, and submit your application. • Revalidating an Individual: A step‑by‑step video for individual providers on updating personal information and submitting Medicaid revalidation in PEMS. • Revalidating a Performing Provider: A step‑by‑step video for performing providers on updating personal informat...

PEMS Additional Revalidation Due Date Extension

Beginning April 9, 2026, providers are eligible for an additional revalidation due date extension of 60 calendar days if they meet the following criteria: The provider’s current revalidation due date is on or before May 31, 2026. The provider has an in-flight revalidation application. Important:  Providers should begin the revalidation process as early as 180 days before their revalidation due date to allow sufficient time to complete the process and maintain their enrollment status.

Correction to Continuous Glucose Monitoring(CGM) Authorization Criteria in TMPPM

On April 1, 2026, TMHP will correct this change to state that clients must be insulin-treated or have a documented history of problematic hypoglycemia to qualify for CGM benefits. Note: These authorization requirements already existed for CGM, but were mistakenly changed inthe TMPPM.

April 2026 Updates in the TMPPM Outpatient Drug Services Handbook

On April 1, 2026, the Texas Medicaid & Healthcare Partnership (TMHP) will update the  Texas Medicaid Provider Procedures Manual (TMPPM), Outpatient Drug Services Handbook  as follows: TMHP will add diagnosis codes M1909, M1919, and M1929 to section 6.133, “Triamcinolone Acetonide.” Providers must submit claims for procedure code J3304 with one of the diagnosis codes that are listed in this section of the  TMPPM  for the claims to be considered for reimbursement. TMHP will add a n...

Texas Medicaid Prior Authorization Update for Onasemnogene Abeparvovec-xioi (Zolgensma) Effective April 1, 2026

Effective for dates of service on or after April 1, 2026, Texas Medicaid will update the prior authorization requirements for onasemnogene abeparvovec-xioi (Zolgensma) (procedure code J3399). Prior authorization requests must include the client’s baseline platelet counts. The provider must assess the client’s safety by continually checking weekly counts for the first month and then every other week for the second and third months until platelet counts return to baseline.

In-Flight Revalidation Application Required to Receive a Second or Third Extension

The Texas Medicaid & Healthcare Partnership (TMHP) and the Texas Health and Human Services Commission (HHSC) are updating the revalidation due date extension process. Beginning February 1, 2026, HHSC is implementing additional criteria for second and third extensions.

Clinical Laboratory Improvement Amendment (CLIA) Frequently Asked Questions

Texas HHSC Clinical Laboratory Improvement Amendment (CLIA), Version 0.6. Please note, all items underlined are new criteria and clarifications that have been added to the CLIA FAQ.

Sarepta Therapeutics Provides Clinical Updates for ELEVIDYS

ELEVIDYS (Delandistrogene moxeparvovec-rokl) (HCPCS code J1413) is an adenoassociated virus vector-based gene therapy indicated for the treatment of individuals aged four years or older with Duchenne muscular dystrophy (DMD) who have a confirmed mutation in the DMD gene.

HHSC Updates Clinical Prior Authorization Criteria Guides

Background: HHSC completed an internal review and updated a series of clinical prior authorization criteria guides. Key Details: HHSC reviewed the clinical prior authorization criteria guides outlined below. The list of changes is published on the VDP website. · Anxiolytics and Sedatives/Hypnotics (ASHs) · Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute · Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis · Corticotropin · Cough and Cold Medications · Cytokine and...

Clarification on the PEMS CHOW Process

This is a clarification to the article titled “Updates for CHOW Available in PEMS Effective June 30, 2023,” which was published on tmhp.com on May 19, 2023. This article provides more information to providers about the Provider Enrollment and Management System (PEMS) change of ownership (CHOW) process. CHOW With Different NPIs If the buyer (new owner) and seller (old owner) have different National Provider Identifiers (NPIs), the following procedures apply: • If the NPI or Atypical Provider Identifier (A...

Prior Authorization Criteria for Anktiva Effective Nov. 1, 2024

Background: On Oct. 1, 2024, Anktiva became a benefit of Medicaid and CHIP. HHSC requires prior authorization for Anktiva (procedure code C9169) for Medicaid and CHIP, effective for dates of service on or after Nov. 1, 2024. Key Details: Anktiva (Nogapendekin Alfa Inbakicept-pmln) is an interleukin-15 (IL-15) receptor agonist indicated to treat adult clients with Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS) with or without papillary t...

Prior Authorization Criteria for Imdelltra Effective Nov. 1, 2024

Background: On Oct. 1, 2024, Imdelltra became a benefit of Medicaid and CHIP. HHSC requires prior authorization for Imdelltra (procedure code C9170) for Medicaid and CHIP, effective for dates of service on or after Nov. 1, 2024. Key Details: Imdelltra (Tarlatamab-dlle) is a bispecific delta-like ligand 3 (DLL3)-directed CD3 T-cell engager indicated for the treatment of adult clients with extensive-stage small cell lung cancer (ES-SCLC) with disease progression on or after platinum-based chemotherapy. Imd...

2025 TMPPM Release Notes

Reminder of Seating Assessment Benefits for Texas Medicaid

This is a reminder that, when appropriate, providers may submit claims for reimbursement on the same date of service for the following procedure codes: • A seating assessment (procedure code 97542) • A physical therapy evaluation (procedure codes 97161, 97162, or 97163) • An occupational therapy evaluation (procedure codes 97165, 97166, or 97167) • A physical or occupational therapy re-evaluation (procedure codes 97164 or 97168) Note: Providers must document distinct start and stop times for each service...

November TMPPM Update for OEFV Services

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. On November 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) ...

TMPPM Update for Continuous Glucose Monitoring Effective November 1, 2025

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. On November 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) ...

Updates to Joint Injections and Trigger Point Injections Benefit Criteria Effective November 1, 2025

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 November 1, 2025, Texas Medicaid ...

Updates to Prior Authorization Criteria for Sickle Cell Disease Gene Therapy

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 October 1, 2025, the Texas Medica...

2025 Texas Flooding: Appeal and Continuation of Benefit Request Extensions

Background: In response to the 2025 Texas flooding, HHSC directs CHIP, STAR, STAR Health, STAR Kids, and STAR+PLUS managed care organizations (MCOs); Medicare-Medicaid Plans (MMPs); and dental maintenance organizations (DMOs) to extend the time members, legally authorized representatives, or authorized representatives have to request an appeal and continuation of benefits. Key Details: Current policy provides members 60 days to request an MCO internal appeal and 10 days to request continuation of benefit...