Prior Authorization

Sometimes the care you get from your provider needs approval from Texas Children’s Health Plan before it takes place. This process is called prior authorization, which means your provider will need to submit a request for approval before giving you the medical service. Texas Children’s Health Plan then decides whether to approve or deny your provider’s request. You will receive a letter if the request is approved. If Texas Children’s Health Plan denies the request, you will get a letter explaining why it was denied.

We have put together the resources below to help you understand how the prior authorization process works.

Require Supporting Clinical Documentation

When Texas Children’s Health Plan receives a request for prior authorization for a Medicaid member under age 21 that does not contain complete documentation and/or information, Texas Children’s Health Plan will return the request to the Medicaid provider with a letter describing the documentation that needs to be submitted. When possible, Texas Children’s Health Plan will contact the Medicaid provider by telephone and obtain the information necessary to complete the prior authorization process.

If the documentation/information is not provided within sixteen (16) business hours of Texas Children’s Health Plan’s request to the Medicaid provider, Texas Children’s Health Plan will send a letter to the member explaining that the request cannot be acted upon until the documentation/information is provided. Texas Children’s Health Plan will also include a copy of the letter sent to the Medicaid provider describing the documentation/information that needs to be submitted. Texas Children’s Health Plan will give the Medicaid provider an additional seven (7) days from the date of your letter to submit the requested documentation.

Prior Authorization Requirements

Click here for an accurate and up-to-date list of prior authorization requirements.

Required Documentation for Prior Authorization

Your provider must submit the Texas Standard Prior Authorization Request Form, which you can view and download here.

The form must include the following information:

• Member Name
• Member Date of Birth
• Member Medicaid/CHIP Identification Number
• Requesting Provider Name and National Provider Identifier (NPI)
• Servicing Provider Name and NPI
• Requested Service
• Current Procedures Terminology (CPT) Codes Requested
• Number of Units Requested
• Dates of Service

Click here to view dates of Texas Children’s Health Plan’s annual review of prior authorization criteria.

Please contact Texas Children’s Health Plan if you have questions or need help with prior authorizations.

Prior Authorization Determinations