Peer to Peer Provider Authorization Communication

Date: April 23, 2021 Attention: All Providers Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Texas Children’s Health plan (TCHP) would like to make providers aware of the standard procedures when they receive a peer to peer letter for a denial or a partial denial as a result of an authorization request. How this impacts providers: The peer to peer process is as follows:

• The provider receives a peer to peer letter for a denial or partial denial explaining that there is an intent to deny and a reason for denial
• The provider has one business day to respond and request a peer to peer phone conversation with a medical director.
• The next business day after the peer to peer letter is sent, a denial letter is sent to the provider. This occurs even if a peer to peer call has already been scheduled. The peer to peer request will be competed as scheduled and the decision may be adjusted after the peer to peer is completed.
• This is a standard procedure that aligns with the Health and Human Services Commission (HHSC) requirement that authorization decisions are issued within a set time frame.

Next steps for providers: Providers should share this communication with their staff. 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.