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 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
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.
- Augmentative Communication Device Guideline
- Bariatric Surgery Guidelines
- Behavioral Health Level of Care TCHP Guideline
- Botulinum Toxin Guidelines
- Case by Case Added Services Procedure
- Circumcision Guidelines
- Clinician Administered Drug Guideline
- Cosmetic Surgery Guidelines
- Cranial Molding Orthosis Guidelines
- Day Activity and Health Services (DAHS) Guideline
- Developmental Screening Guidelines
- Durable Medical Equipment (DME) Repair Guideline
- Durable Medical Equipment (DME) Service Procedure
- Gait Trainers and Standers Guidelines
- General Anesthesia for Dental Procedures in Members 6 years old and Younger
- Genetic Testing Guidelines
- Hearing Device Guideline
- Home Health Guidelines
- Home Health Skilled Nursing (SN) and Home Health Aid (HHA)
- Hospital Bed Guidelines
- Hospital Inpatient Care Guidelines
- Inpatient Rehabilitation Services Guideline
- Miscellaneous Durable Medical Equipment (DME) (E1399) when billed amount exceeds $500
- Monoclonal Antibodies Guideline
- Non-Invasive Prenatal Testing (NIPT) - Genetic Testing Guidelines
- Non-Emergency Ambulance Guidelines
- Nutritional Supplements Guideline
- Occupational Therapy Guidelines
- Oral Surgery Guidelines
- Organ Tissue Transplant Guidelines
- Orthoses Guideline
- Out of Network Services Guideline
- Outpatient Psychotherapy Visits Greater than 30 per Calendar Year
- Physical Therapy Guidelines
- Positive Airway Pressure (PAP) Device Guidelines
- Positron Emission Tomagraphy (PET) Scan Guidelines
- Private Duty Nursing (PDN) Guidelines
- Progesterone Therapy Guidelines
- Prosthetics Guidelines
- Psychological/Neuropsychological Testing Guidelines
- Secretion and Mucous Clearance Devices Guideline
- Skills Training Request for CHIP Members Guideline
- Sleep Studies in Children Guidelines
- Single Photon Emission Computed Tomography (SPECT) Scan Guidelines
- Speech Therapy Guidelines
- Targeted Case Management & Mental Health Rehabilitation Guideline
- Telemonitoring Guideline
- Temporomandibular Joint (TMJ) Guidelines
- Therapeutic and Reconstructive Breast Procedures Guideline
- Therapeutic Continuous Glucose Monitors (CGMs)
- Utilization Management COVID-19 Procedures
- Wheelchairs Guidelines