STAR & CHIP Providers

• 4-1-21 Update Enrollment and Demographic Information
• 12-28-20 Important Update on COVID-19 Vaccines
• 9-10-20 Certain COVID-19 Procedure Codes Implemented Retroactively
• 5-27-20 Date of Service Extension for Telemedicine Physician-Delivered and Telehealth
• 5-14-20 Updated Guidance: Texas Health Steps Medical Checkups via Remote Delivery
• 5-14-20 Top 10 Key COVID-19 Flexibilities
• 5-8-20 THSteps Medical Checkups via Remote Delivery
• 4-28-20 Types of Telemedicine Virtual Visits-Texas Medicaid
• 4-28-20 Claims for Telephone (Audio-Only) Nutritional Counseling Services
• 4-28-20 Claims for Telephone (Audio-Only) Early Childhood Intervention Specialized Skills Training
• 4-24-20 COVID-19 Guidance Targeted Service Coordination Through Remote Delivery
• 4-20-20 Temporary Change in Status for Oral Immunosuppressives Drug Class
• 4-14-20 Claims for Telehealth Service for Occupational, Physical and Speech Therapy
• 4-1-20 Provider Enrollment Revalidation Due Dates Extended in Response to COVID-19
• 3-30-20 RHC Reimbursement for Telemedicine and Telehealth Services
• 3-24-20 Client Signature Requirement Waived on DME Certification and Receipt Form
• 3-20-20 Claims for Telephone (Audio Only) Medical Services
• 3-20-20 Claims for Telephone (Audio Only) Behavioral Health Services
• 3-18-20 FQHC Reimbursement for Telemedicine Phys Delivered and Telehealth Non-Phys
• 3-16-20 Coronavirus Testing Procedure Codes to Become a Benefit

Click on the links below to view/download FirstCare's Provider Credentialing forms:

• Institutional Provider Credentialing Application (For application instructions, click here.)
• Expedited Credentialing Addendum
• Mid-Level Hospital Waiver
• Texas Standardized Credentialing Application
• Practitioner Credentialing Checklist
• Facility Initial Checklist
• Letter of Interest
• W-9

The expedited credentialing process allows providers to participate in the FirstCare network on a provisional basis. This provisional status is available if:

• Provider is a first time applicant to FirstCare and provisional credentialing request is based on a critical need of the members.
• Provider is joining as a partner, shareholder or employee of a currently contracted and credentialed FirstCare provider in good standing.
• Provider has submitted the appropriate paperwork, including a complete Texas Standard Credentialing Application with current attestation.
• The applicable Regional Medical Director has reviewed the request and determined the application cannot be completed in 30 days or less.
• The required verifications must indicate the file is clean. This includes a state license in good standing with the appropriate medical board, as well as a clean NPDB query.

All provisionally approved providers must agree to comply with the terms of the FirstCare contract currently in force with the applicant physician's established medical group. The full credentialing process must be completed within 60 calendar days of the date a physician is granted provisional status.

FirstCare monitors compliance for availability of services standards. In order to ensure the best quality of care for our members, we ask participating providers to operate within the standards described in the Minimum Requirements for Provider Availability of Services.

• View/download the FirstCare STAR & CHIP Provider Training Workshop
• View/download the FirstCare STAR & CHIP Provider Resource Book
• HHSC External Medical Review (EMR) Provider Training

An effective health communication is as important to health care as clinical skill. To improve individual health and build healthy communities, health care providers need to recognize and address the unique culture, language and health literacy of diverse consumers and communities.

Additional cultural competency resources can be found on the U.S. Department of Health and Human Services Office of Minority Health website.

Pharmacy Benefit Drugs

• FirstCare is state mandated to adhere to the Texas Medicaid Formulary, Preferred Drug List, Provisional Formualry, and Preferred Drug List Criteria Guide which are developed and maintained by the Texas Drug Utilization Review (DUR) Board and Texas HHSC Vendor Drug Program (VDP). Additional information regarding VDP including formularies, preferred drug list, and Texas DUR Board meeting minutes and updates can be found on the Texas Vendor Drug Program webpage.
• The Texas Medicaid formulary and Preferred Drug List are available on the Epocrates drug information system. The service is free and provides instant access to information about the Texas Medicaid formulary through the internet or a handheld device.
• The Texas STAR Formulary is available in paper form without charge. To request a copy, please call FirstCare STAR Customer Service at 1-800-431-7798.

Medical Benefit Drugs

• For list of drugs covered under medical benefit, please refer to the Texas Health and Human Services Vendor Drug Program Formulary – Clinician-Administered Drug found here: Data Files | Vendor Drug Program.

Pharmacy Benefit Drugs

• FirstCare administers the prior authorization criteria approved by the Texas DUR Board. For a listing of clinical edits implemented by FirstCare please click here, and for access to FirstCare's prior authorization forms please click here.
• To obtain pharmacy prior authorization assistance for Medicaid CHIP, please call FirstCare Medicaid CHIP PBM, Navitus, Toll Free at 877-908-6023 and select the prescriber option to speak with the Prior Authorization department between 6 a.m. to 6 p.m. weekdays and 8 a.m. to noon weekends Central Time (CT), excluding state approved holidays.
• Download the State of Texas Standard Prior Authorization Form for prescription benefit drugs
• CHIP Pharmacy Prior Authorization Timeline
  • For routine PA requests within three Business Days after receipt
  • For urgent PA request within 1 Business Day
• STAR Pharmacy Prior Authorization Timelines
  • If the prescriber's office calls the MCO's PA call center, the MCO must provide prior authorization approval or denial immediately.
  • For all other PA requests, the MCO must notify the prescriber's office of a PA denial or approval no later than 24 hours after receipt.
  • If the MCO cannot provide a response to the PA request within 24 hours after receipt or the prescriber is not available to make a PA request because it is after the prescriber's office hours and the dispensing pharmacist determines it is an emergency situation, the MCO must allow the pharmacy to dispense a 72-hour supply of the drug.

Medical Benefit Drugs

• For information regarding prior authorization submission for drugs obtained under the medical benefit, please refer to Authorization Information

A 72-hour emergency supply of a prescribed drug may be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring a prior authorization (PA), either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical edits.

The 72-hour emergency supply may be dispensed when a PA cannot be resolved within 24 hours for a medication on the Vendor Drug Program formulary that is appropriate for the member's medical condition. If the prescribing provider cannot be reached or is unable to request a PA, the pharmacy should submit an emergency 72-hour prescription. The emergency supply is subject to pharmacist clinical judgement. Some non-urgent medications are exempt from this emergency supply.

A pharmacy can dispense a product that is packaged in a dosage form that is fixed and unbreakable, e.g., an albuterol inhaler, as a 72-hour emergency supply.

To be reimbursed for a 72-hour emergency prescription supply, pharmacies should submit the following information:

Place '8' in "Prior Authorization Type Code" (Field 461-EU), '801' in "Prior Authorization Number Submitted" (Field 462-EV) and '3' in "Days' Supply" in the claim segment of the billing transaction (Field 405-D5). The quantity submitted in "Quantity Dispensed" (Field 442-E7) should not exceed the quantity necessary for a three-day supply. It is permissible that a pharmacy dispense product packages in fixed dosage forms (e.g., inhalers, nebulized medications) that are unbreakable as a 72-hour supply. Place '3' in "Days' Supply" but enter the full quantity dispensed.

• To obtain a copy of the Pharmacy Provider Manual, please visit www.navitus.com.
• For Pharmacy questions contact FirstCare Customer Service at 1-800-431-7798.

• To obtain a copy of the MAC List, network pharmacies may visit the Navitus pharmacies website and go to the MAC Program link: pharmacies.navitus.com