Introducing New Enhancements to the Authorization Process
Date: April 2, 2026
Attention: Providers
Effective date: April 13, 2026
Announcement: Texas Children’s Health Plan (TCHP) is excited to announce new enhancements designed to elevate your experience. TCHP is introducing changes to improve the determination letter process and communication. These updates improve how authorization decisions are reviewed and communicated by introducing a new out-of-network determination process, eliminating post-claim retrospective reviews, and consolidating determination letters.
What Is Changing:
New Out-of-Network (OON) Review Process
- Requests for out-of-network services may result in administrative denials if an in-network provider is available to deliver the requested services.
- If an in-network option is available, that availability will be reflected in the determination outcome.
Administrative Denials
- Administrative denials will be issued as formal determinations based on network availability.
- These determinations will be clearly communicated within authorization letters.
Provider Impact:
- Out-of-network requests may be denied if medically appropriate services are available in-network.
- Determination outcomes support network integrity while ensuring access to appropriate care.
Retrospective Reviews
Retrospective reviews will no longer be conducted once a claim has been submitted. Reviews must occur prior to claim submission to be considered. Therefore, authorization questions and requests should be addressed before claims are submitted.
Combined Authorization Letters
- When multiple services are requested at the same time, providers will receive a single combined letter, even when different determinations apply.
- One combined letter may include:
- Approved services
- Denied services
- Services for which no authorization is required
What Is Not Changing
- Clinical criteria or medical necessity standards
- Authorization submission processes
- Review turnaround timelines
Where to learn more: For a demonstration of the enhancements click here. (will link to Video).
If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org.
For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.