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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.
Providers should use the calculator to calculate the DOS that must be applied to the prior authorization form/prior authorization request.
Dates of service (DOS) calculator
Source: https://www.tmhp.com/topics/prior-authorization
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:
For additional information regarding medication related pharmacy prior authorizations, see links below.
Members:
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.
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
Within one hour for post-hospitalization or life-threatening conditions, TCHP does not require prior authorization.
Post hospital discharge services | Within one business day
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.