TMPPM Prior Authorization Rules

Automated extraction from the Texas Medicaid Provider Procedures Manual

The only CMS-0057-F platform that ingests the Texas Medicaid Provider Procedures Manual (TMPPM) directly from TMHP, extracts prior authorization rules at the procedure-code level, and serves them through the CRD endpoint in real time. No manual questionnaire authoring. No monthly spreadsheet maintenance.

PA categories extracted

TMPPM chapters covered

Monthly

Auto-refresh cycle

<$1

Per extraction run

The Problem

Manual TMPPM tracking falls entirely on plan staff, who must read PDFs, identify changes, and update prior-authorization questionnaires by hand every month. Generic payer-platform questionnaires are not Texas Medicaid-specific, so plan staff must bridge the gap themselves.

CHO eliminates this manual burden entirely with an automated extraction pipeline that reads the same TMHP PDFs and produces structured, queryable PA rules.

From PDF to CRD Response in One Pipeline

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1. Download TMPPM chapters

8 priority PDF chapters pulled directly from tmhp.com. Each file SHA256-hashed for month-over-month change detection. Only changed chapters get re-parsed.

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2. Extract PA sections

PyMuPDF locates all 50 “Prior Authorization” sections by TMPPM reference number. Skips table-of-contents entries, finds the body text with clinical criteria, procedure codes, and documentation requirements.

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3. Hybrid regex + LLM extraction

Regex catches CPT/HCPCS codes and age rules from clean sections. Sections with low regex confidence escalate to Claude API for structured extraction — clinical criteria, diagnosis restrictions, unit limits, documentation requirements.

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4. Persist to Cosmos DB

Rules stored as ConceptMapEntry overrides with State=TX, IsOverride=true, and optional TenantId for plan-specific scoping. Same collection the TerminologyService queries at runtime.

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5. CRD server responds

Provider submits a CRD check → CHO queries Cosmos → returns Texas-correct “auth required” or “no auth” with the TMPPM section reference and clinical criteria. Sub-second response, zero manual lookup.

TMPPM extraction pipeline diagram showing the flow from TMHP PDF download through SHA256 change detection, PyMuPDF section extraction, hybrid regex and LLM enrichment, Cosmos DB persistence, to CRD server response

End-to-end TMPPM extraction pipeline — from TMHP PDF to CRD response

Validated Extractions — April 2026 TMPPM

These are real rules extracted from the current TMPPM edition, verified against the source PDFs:

Hypoglossal nerve stimulators

§9.2.46.14 — PA required for surgical implantation. OSA diagnosis with failed CPAP compliance or seizure diagnosis. DISE procedure required for OSA.

645826458364584

Bariatric surgery

§9.2.8.1 — BMI ≥35 adults (≥40 pediatric). 13 qualifying comorbidities. Psych eval required. 6-month structured diet program. MBSAQIP facility accreditation.

LLM enrichment

Hyperbaric oxygen therapy

§9.2.33.1 — Session limits per covered indication. Air embolism: 6 intervals. Carbon monoxide: 15 initial, 9 subsequent. Central retinal artery: 36 intervals.

99183G0277

Organ transplants

§9.2.51.1 — General PA requirements. Contraindications: pulmonary HTN, uncontrolled HIV, psychiatric instability. 3-day pre / 6-week post denial window.

Category-level

HCPCS Q1 2026 updates

April 1, 2026 effective. New PA-required codes and diagnosis-restricted drugs. Auto-ingested from TMHP quarterly bulletins.

C8007C8011J3404L2221J9601J9248

Neurostimulators

§9.2.46 — 10 sub-categories: dorsal column, vagal nerve, sacral nerve, intracranial, pelvic floor, gastric, TENS, NMES, PENS, diaphragm-pacing.

50+ CPT codes

Competitive Comparison

How CHO’s automated TMPPM extraction compares to manual questionnaire-based approaches:

Capability	Cognizant TriZetto EPA	CHO TMPPM Engine
State-specific PA rules	✗ None — 130 generic questionnaires	✓ 50 TX categories, code-level
TMPPM monthly tracking	✗ Manual — plan staff responsibility	✓ Automated SHA256 change detection
HCPCS quarterly updates	✗ Not included	✓ 8 Q1 2026 rules loaded
SNOMED↔CPT translation	✗ “Go buy from a vendor”	✓ Built-in TerminologyService
Clinical criteria extraction	✗ Not digitized	✓ LLM-assisted structured extraction
Tenant scoping	Single-tenant	✓ Per-plan overrides (tenant-scoped)
Completed implementations	✗ Zero as of March 2024	✓ Pipeline running, data in Cosmos

PA Rule Explorer

The PA Rule Explorer is a Blazor Server page in the CHO portal that gives plan administrators and UM staff direct access to the extracted TMPPM rules:

Search by CPT/HCPCS code — type a procedure code and instantly see whether PA is required, the clinical criteria, required documentation, and the TMPPM section reference
Browse by category — expandable tree of all 50 PA categories grouped by priority (P1 Auth Required, P2 Limits & Restrictions, P3 Other)
Edition metadata — which TMPPM edition is loaded, last refresh timestamp, and a freshness indicator (green <30 days, amber 30–60, red >60)
Month-over-month diff — added, modified, and removed rules with before/after comparison between any two editions

Access the PA Rule Explorer at /compliance/pa-rules in the Blazor portal. Requires the compliance:read or authorizations:read permission.

Technical Architecture

Data Model

Extracted rules are stored in three Cosmos DB (MongoDB API) collections in the cho_terminology database:

Collection	Purpose
`tmppm_pa_rules`	Raw extracted rules with clinical criteria, CPT/HCPCS codes, age limits, documentation requirements
`tmppm_editions`	Version tracking with SHA256 per chapter, publication date, ingestion timestamp
`concept_map_entries`	`ConceptMapEntry` overrides queried by the CRD server at runtime (`IsOverride=true`, `State=TX`)

Tenant Scoping

All rules are tenant-scoped with TenantId (e.g., txmco01). The CRD server merges global rules with tenant-specific overrides at query time, allowing plans to customize PA requirements while inheriting the platform baseline.

Extraction Pipeline

The TmppmIngestionService is a .NET 8 console application in tools/CloudHealthOffice.TmppmIngestionService:

TmhpChapterDownloader — fetches PDFs from TMHP, SHA256 hashes for change detection
TmppmPdfParser — PdfPig-based text extraction with regex pattern matching for procedure codes, age rules, and section references
extract_section.py — PyMuPDF script for targeted section extraction when PdfPig has layout issues
IngestionPipeline — orchestrates download → parse → store, with LLM escalation for complex clinical criteria
TmppmRuleStore — MongoDB upsert logic with edition versioning and diff report generation

Monthly Refresh Cycle

TMHP publishes updated TMPPM chapters monthly. CHO’s refresh cycle:

Download — all 8 priority chapters fetched from TMHP
Compare — SHA256 hash compared to previous edition; unchanged chapters skipped
Extract — changed chapters re-parsed; new/modified rules identified
Diff report — TmppmDiffReport generated with added, modified, and removed deltas
Publish — new ConceptMapEntry overrides upserted; previous edition preserved for audit
Notify — rules flagged RequiresHumanReview=true appear in the PA Rule Explorer diff view for UM staff review

Cost: Each full extraction run costs less than $1 in Claude API calls. Regex handles ~70% of sections; only complex clinical criteria sections escalate to the LLM.

TMPPM Chapters Covered

Chapter	Title	PA Categories
`1_05`	Prior Authorization	Master PA category list and general requirements
`2_01`	Ambulance Services	Air ambulance, non-emergency transport
`2_02`	Behavioral Health	Inpatient psych, residential treatment, ABA
`2_06`	DME and Supplies	Power wheelchairs, orthotics, prosthetics
`2_11`	Inpatient/Outpatient Hospital	Transplants, bariatric, cardiac procedures
`2_13`	Medical Specialties & Physician Services	Neurostimulators, HBOT, pain management, imaging
`2_16`	PT/OT/ST Services	Therapy visit limits, specialized rehab
`2_17`	Radiology and Lab	Advanced imaging PA requirements