Authorization requests may be submitted to Texas Children’s Health Plan by faxing the authorization form and required documentation to 832-825-8760 or calling 832-828-1004. Behavioral Health authorizations may be sent to Behavioral Health toll-free Fax 1-844-291-7505.
When a UM Specialist is unable to approve the requested service based on Texas Children’s Health Plan criteria, the Medical Director/Associate Medical Director/Physician Reviewer will review the authorization request and any available clinical information, prior to issuance of any denial based on lack of medical necessity. Before a denial is issued by Texas Children’s Health Plan regarding the medical necessity or appropriateness, or the experimental or investigational nature, of a healthcare service, Texas Children’s
Health Plan provides the requesting provider a reasonable opportunity to discuss with a physician the patient’s treatment plan and the clinical basis prior to the adverse determination. A decision to deny a service authorization based on medical necessity can only be made by a physician.
If a request for services is denied by Texas Children’s Health Plan, the ordering provider, rendering provider and member will receive a letter indicating the reason why services are being denied. The member, member designee, practitioner or provider has the right to appeal a denial of services.
Members may represent themselves or be represented by the health care provider, a friend, a relative, legal counsel, or another spokesperson. Texas Children’s Health Plan will make a decision within 30 days of receiving the request for appeal.
It is the policy of Texas Children’s Health Plan to use written criteria based on clinical evidence for appropriate case application in adjunct to a review of individual circumstances and local health system structure when determining medical appropriateness of health care services.
Texas Children’s Health Plan has developed Utilization Management guidelines that are objective and based on Medical evidence to serve as criteria for the determination of medical necessity for services that require prior authorization. The goal of our UM guidelines is to encourage the highest quality care from the right provider in the right setting. To access the Guidelines providers may log in to the provider portal at www.tchp.us/providers or contact Texas Children’s Health Plan Provider Relations department at 832-828-1008 or toll-freee at 1-800-731-8527.
Our Prior Authorization requirements are available on our website, click here to view Prior Authorization.
Prior Authorization forms for private duty nursing and therapy can found on our website, click here for Prior Authorization Request form and Standard Prior Authorization form.
A toolkit for speech therapy, physical therapy, and occupational therapy is available on our website, click here for Provider Resources.
Clarification on Continuity of Care for STAR Kids
Texas Children’s Health Plan follows the Texas Medicaid Provider Procedures Manual. Section 5 (5.1) permits prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients to sign prior authorization forms and supporting documentation using electronic or wet signatures.
For information on billing and claim administration, please refer to our Provider Manual.
It is the responsibility of all treating providers to verify that the patient continues to be a Texas Children’s Health Plan member throughout the treatment period. Verification of eligibility may be made by:
Visiting Texas Children’s Health Plan online at www.tchp.us/providers (Providers must fill out the Texas Children’s Health Plan Secure Access Application to become an authorized user. For more information on Texas Children’s Health Plan’s secure access call Provider Relations at 832-828-1008.
STAR Kids Providers can receive eligibility information by calling the STAR Kids Provider Eligibility Hotline Monday through Friday 8:00 AM to 5:00 PM (Central Time). Providers who call the hotline can speak with a customer service representative to confirm whether a child is a currently enrolled STAR Kids Member. The hotline number is 832-828-1004 or toll free at 1-877-213-5508.
Information on upcoming provider events can be found on our Provider Events page.
To request information about training, please contact our Provider Relations team.
Information about becoming a participating provider can be directed to our network development team, click here to learn more about becoming a participating provider.
Texas Children’s Health Plan follows the LTSS guidelines for PCS, CFC, PDN, and MDCP listed in the STAR Kids provider handbook.
Electronic Visit Verification
For information on EVV, please see information on our Provider Resources page.
HHS STAR Kids
Visit the HHS STAR Kids website at https://hhs.texas.gov/services/health/star-kids.