Retrospective Review Policy & Procedure

Date: January 30, 2026

Attention: All Providers

Effective Date: March 1, 2026

Call to action: Texas Children’s Health Plan (TCHP) would like to bring to your attention recent modifications to our Retrospective Authorization Review requirements. TCHP may retrospectively review requests only when prior authorization was required but not obtained and a claim has not yet been submitted. Providers must comply with TCHP Utilization Management (UM) authorization procedures. Failure to follow prior authorization requirements may result in a nonmedical necessity denial. TCHP’s Prior Authorization Information is available at https://www.texaschildrenshealthplan.org/providers/provider-resources/prior-authorization-information.

Circumstances Eligible for Retrospective Medical Necessity Review

Retrospective Member Enrollment

Retrospective medical review may be completed when:

• Prior authorization was required but could not be obtained because the member was retrospectively enrolled.
• Authorization request is submitted within 30 calendar days of retrospective enrollment and before claim submission.
• Supporting clinical documentation substantiates the member’s retrospective enrollment scenario.

Late Coverage Identified

TCHP may conduct retrospective review when:

• Member coverage is identified after services are rendered and prior authorization was required.
• Authorization request is submitted within 30 calendar days of the initial date of service and prior to claim submission.
• Supporting documentation substantiates the identified coverage delay.

Extenuating Circumstances

TCHP may conduct retrospective review when extenuating circumstances prevented timely authorization, including:

• Coverage identified late when authorization was required.
• Catastrophic events that disrupted provider operations or delayed access to records (e.g., system failures, natural disasters).
• Additional medically necessary services are identified and performed during a scheduled service requiring authorization.
• Incorrect information was provided by TCHP that led the provider to believe authorization was not required.

Submitting Requirements

• Authorization requests must be submitted within 30 calendar days of the date of service (or date of claim denial for misinformation cases).
  • Network providers should submit Prior Authorization requests via Texas Children’s Link at https://www.texaschildrenshealthplan.org/providers/link-provider-portal. Out of network providers should reference the fax lines at https://www.texaschildrenshealthplan.org/providers/provider-resources/prior-authorization-information.
• All requests must include supporting clinical documentation substantiating the extenuating circumstance.

Retrospective Review Will Not Be Performed (NonMedical Necessity Denials)

TCHP will not conduct a retrospective medical necessity review in the following situations:

• A prior authorization or concurrent review was previously requested and received a partial or full denial following medical review.
• A claim was submitted before requesting authorization (except where extenuating circumstances apply).
• Provider did not follow required TCHP UM authorization procedures.
• Services requiring prior authorization were rendered without one, and no extenuating circumstance or retroeligibility applies.

These situations result in a nonmedical necessity administrative denial.

Start of Care (SOC) Requirements

TCHP allows initiation of certain services prior to authorization only within required SOC timeframes. These requests will be reviewed as standard prior authorization (not retrospective) when submitted within SOC rules.

SOC Submission Windows

Additional SOC Rules

• Claims must not be submitted before the related authorization is approved.
• Continuationofcare services must follow standard prior authorization process; retrospective review is not permitted for continuation requests.
• Requests missing essential information are rejected per UMCM 3.22 (Incomplete Prior Authorizations).

Important Distinction: Claims vs. Retrospective Authorization Review

• Requests submitted after a claim has been filed and denied are considered claim disputes, not retrospective authorization requests.
• These follow the TCHP Claims Appeal Process and are not eligible for retrospective medical review.

Next step for Providers:

• Review your internal workflows to ensure prior authorization requirements are followed.
• Submit authorization requests timely and before claim submission.
• Ensure SOC timelines are followed for services permissible to start before authorization.

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

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