Prior Authorization Information | Texas Children's Health Plan

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Prior Authorization Information

  1. Provider Resources
  2. 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

Prior Authorization Fax Lines

  • 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

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 2 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.
 
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
 
Life-threatening conditions |  Within one hour
 
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.