Prior Authorization Information
External Medical Review Provider Training from Health and Human Services is available here for all providers. For more information on External Medical Review click here.
Authorizations
- Standard Prior Authorization Form
- Prior Authorization Requirements
- Prior Authorization Reference Information
- Prior Authorization Update Summary
- Clinical and Administrative Advisory Committee - Annual Review Summary
- Authorization Process Required Information
- Prior Authorization Annual Review Report
Prior Authorization Fax Lines
- Medical Inpatient Admissions and Discharge Notifications - 832-825-8462 or Toll-Free 844-663-7071
- 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
- LTSS and Private Duty Nursing Fax Line - 346-232-4757 or Toll-Free 1-844-248-1567
- Post Hospital Discharge Authorizations Fax Line - Toll-Free 866-839-9879
Contact Us
Please contact us if you have questions or need assistance with prior authorizations.
Providers: 1-800-731-8527
Providers may also reach out to their Provider Relations Liaison, contact information is available here.
For information on hours of operation and more details, please click here. One of our representatives will contact you within two hours or within one business day for calls received on nights, weekends and holidays.
Utilization Management Hours of Operation:
Monday through Friday 8 a.m. to 6 p.m. CST
Pharmacy Benefit (Retail Drug) Prior Authorization
For medication authorization inquiries, providers and pharmacies should contact the Navitus Prior Authorization Department at 1-877-908-6023. Requests for appeals should be directed to Texas Children’s Health Plan.
Timeline for Prior Authorization requests made with Navitus:
- If the prescriber calls the prior authorization call center, the approval or denial decision occurs immediately
- For routine and urgent requests, the approval or denial is made within 24 hours
- If a prior authorization is not received within 24 hours, or the provider is not available to make request, the pharmacy can give a 72 hour emergency supply if the pharmacist determines it is an emergent situation. Source: https://txstarchip.navitus.com/
For additional information regarding medication related pharmacy prior authorizations, see links below.
- Navitus Prior Authorization Frequent Asked Questions
- Navitus' Prior Authorization Forms
- Navitus' Clinical Edit Form
Members:
CHIP 1-866-959-6555
STAR 1-866-959-2555
STAR Kids 1-800-659-5764
Our Member Services team is ready to take your call from 8 a.m. to 5 p.m., Monday through Friday. After hours, on weekends and holidays, our answering service is ready to help you and/or take your messages. A Member Service Advocate will return your call the next business day.
We speak English or Spanish. We also have interpreters available by phone who speak 140 different languages.
Texas Children’s Health Plan offers TDD.TTY services for deaf, hard of hearing or speech impaired members and providers. For TDD assistance, please call 1-800-735-2989 or 7-1-1.
Prior Authorization Determinations
The Utilization Management department processes service requests in accordance with the clinical immediacy of the requested services.
Authorization | Turnaround Time
Routine | Within 3 business days after receipt of request
Urgent | Within 1 business day after receipt of request
Inpatient | Within 1 business day after receipt of request
TCHP does not require prior authorization for Emergency Medical Conditions or Emergency Behavioral Health Conditions
Post hospital discharge services | Within one business day
Prior Authorization Guidelines
Below you will find all of the Prior Authorization Guidelines. If you wish to open the following forms, you must have Adobe Acrobat Reader installed on your computer. To download a form, right click on one of the links below and select "Save Target As."
Providers should reference the guidelines listed below for a specific service. Each guideline lists the required documentation and forms that must accompany an authorization request.
Download a free copy of Adobe Acrobat Reader, click here.
- Augmentative Communication Device Guideline
- Autism Services Guideline
- Bariatric Surgery Guideline
- Behavioral Health Level of Care TCHP Guideline
- Botulinum Toxin Guideline
- Case by Case Added Services Procedure
- Case Management for Children and Pregnant Women (CPW) Guideline
- Circumcision Guideline
- Clinician Administered Drugs Guideline
- Community First Choice Plan Policy
- Community First Choice Plan Procedure
- Cosmetic Surgery Guideline
- Cranial Molding Orthosis Guideline
- Day Activity and Health Services Guideline
- Developmental Screening Guidelines
- Durable Medical Equipment (DME)
- Durable Medical Equipment (DME) Service Procedure
- Functional Endoscopic Sinus Surgery Guidelines
- Gait Trainers and Standers Guideline
- General Anesthesia for Dental Procedures in Members 6 years old and Younger
- Genetic Testing Guideline
- Hearing Device Guideline
- Home Health Skilled Nursing (SN) and Home Health Aid (HHA)
- Hospital Bed Guideline
- Hospital Inpatient Care Guideline
- Inpatient Rehabilitation Services Guideline
- Maternal Magnetic Resonance Imaging (MRI)
- Medically Dependent Children Program Procedure
- Miscellaneous Durable Medical Equipment (DME) when billed amount exceeds $500
- Monoclonal Antibodies Guideline
- Non-Invasive Prenatal Testing Guideline
- Non-Emergency Ambulance Guideline
- Nutritional Supplements Guideline
- Occupational Therapy Guideline
- Oral Surgery Guidelines
- Organ Tissue Transplant Guideline
- Orthoses Guideline
- Out of Network Services Guideline
- Outpatient Psychotherapy Visits Greater than 30 per Calendar Year
- Personal Care Services Procedure
- Physical Therapy Guideline
- Positive Airway Pressure (PAP) Device Guideline
- Positron Emission Tomagraphy (PET) Scan Guideline
- Prescribed Pediatric Extended Care Center (PPECC)
- Private Duty Nursing (PDN) Guideline
- Progesterone Therapy Guideline
- Prosthetics Guideline
- Psychological/Neuropsychological Testing Guideline
- Secretion and Mucous Clearance Devices Guideline
- Skills Training Request for CHIP Members Guideline
- Sleep Studies
- Single Photon Emission Computed Tomography (SPECT) Scan Guideline
- Speech Therapy Guideline
- Telemonitoring Guideline
- Therapeutic and Reconstructive Breast Procedures Guideline
- Therapeutic Continuous Glucose Monitors (CGMs)
- Utilization Management COVID-19 Procedures
- Wheelchairs Guideline