Reminder: Authorization Guidelines for a hospitalized member - post discharge services and supplies

Attention: All ProvidersEffective Date: May 20, 2020 Call to action: Texas Children’s Health Plan (TCHP) is aligned with the Uniform Managed Care Contract (UMCC) Guideline for members with an authorization request during hospitalization (reference: 8.1.8 Utilization Management). The guideline states that TCHP must issue coverage determinations for a member who is hospitalized at the time of the request, within one Business Day of receiving the request for services or equipment that will be necessary for the care of the Member immediately after discharge. This is whether an Out-of-Network Provider, Provider of Acute Care Inpatient Care Services, or a Member submits the request.  For an authorization request when a Member is hospitalized, providers must do the following:

• Mark the request STAT/URGENT/MEMBER HOSPITALIZED and submit by fax only. Prior Authorization Fax numbers are as follows:
  • Medical Services Fax Line - 832-825-8760 or Toll-Free 1-844-473-6860
  • Behavioral Health Services Fax Line - 832-825-8767 or Toll-Free 1-844-291-7505
• Prior authorization form
• DO NOT utilize Clear Coverage for these requests. Urgent authorization request are not immediately visible to the Utilization Management Department.

  How this impacts providers: Providers will receive their prior authorization determinations within the timelines outlined in the guidelines. Next steps for providers: Providers should remind their staff of these guidelines to ensure compliance. Prior Authorization Determinations: the Utilization Management department processes service requests in accordance with the clinical immediacy of the requested services.  

Authorization	Turnaround time
Routine request for authorization of services	Within 3 business days after receipt of request
Member who is hospitalized at the time of the authorization request	Within 1 business day after receipt of request
For post-stabilization or life-threatening conditions, except that for Emergency Medical Conditions and Emergency Behavioral Health Conditions, TCHP does not require prior authorization.	Within one hour after receipt of the request
For urgent requests	Within 1 business day after receipt of request

  If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.