Reminder Notification of Rejection Notices & Administrative Denials

Date: March 4, 2026

Attention: Providers

Effective date: April 15, 2026

WHY THIS MATTERS

Texas Children’s Health Plan (TCHP) follows HHSC requirements for handling Rejections and Administrative Denials in the prior authorization (PA) process. This notice serves to remind providers of the correct procedures.

REJECTIONS

When it happens: Upon receipt of a PA request. 
Why it happens:

• Required fields in the PA form are missing, incorrect, or illegible
• Provider status in the Texas Medicaid Provider Enrollment and Management System (PEMS)
  • Provider status in the Texas Medicaid PEMS system must be accurate to avoid administrative rejections
  • Inaccurate or outdated PEMS information may affect Medicaid enrollment status
  • Effective April 15, 2026, TCHP will reject PA requests from providers who are not actively enrolled in Texas Medicaid at the time of submission

Examples:

• Missing or inaccurate documentation on the authorization form (e.g., number of units, missing/incorrect CPT codes, start/end dates, incorrect NPI number/taxonomy)
• PEMS status shows provider is not enrolled in Texas Medicaid, as indicated in table below

Next step for Providers:

• Ensure accurate provider information in PEMS
• Correct and resubmit the authorization request when the reason for rejection is resolved
• Rejections may not be appealed

ADMINISTRATIVE DENIAL

When it happens: Upon receipt of PA request.
Why it happens:

• Out of Network (OON) requests
• Request exceeds benefit limits including quantity/frequency limits
• Member not eligible
• ·Experimental procedures
• PA request submitted after services/equipment delivered and claims have been submitted

Examples:

• When the referring, requesting or requested provider is out of network
• When requested services exceeds coverage or benefit limits and are not subject to medical necessity review per EPSDT or extenuating circumstances requirements
• The Member is not eligible for requested services

Next steps for Providers: First line appeal only on member’s behalf (subject to appeal rules and requirements). Not subject to external appeal and Fair Hearings.

BEST PRACTICES TO AVOID DELAYS

✔ Maintain PEMS Accuracy

• Keep provider enrollment status in PEMS up to date. This includes but not limited to, practice locations, taxonomies, and enrollment information.
• Providers should refer to Texas Medicaid requirements for enrollment and maintaining status as an actively enrolled Texas Medicaid provider
• Update changes promptly to prevent authorization issues

✔ Submit Complete PA Requests

• Ensure all forms are the latest versions and ensure all essential information is notated
• Verify codes, units, dates, and eligibility

✔ Understand Next Steps

• Rejections: Fix errors → Resubmit
• Administrative Denial: Ensure in- network status (unless request meets TCHP policy for continuity of care), benefit limits and eligibility. → Appeal if appropriate

PROVIDER RESOURCES
Providers should stay informed about Texas Medicaid requirements for provider enrollment and PEMS updates.

• PEMS Provider Webinar Q&A
• Provider Enrollment Help
• PEMS Instructional Site
• TCHP PEMS FAQ 5.5.2025.pdf

If you have any questions, please email Provider Relations at providerrelations@texaschildrens.org. 

For access to all provider alerts www.texaschildrenshealthplan.org/provideralerts.