Authorization and Verification Process Updates

Authorization and Verification Process Updates

Authorization and Verification Process Updates                                  

Texas Children’s Health Plan has made updates to the authorization process.

Individual Member Fax Requests

To ensure Health Insurance Portability and Accountability Act (HIPAA) compliance, providers must send one fax request per member with each fax having its own cover sheet.

Requests received with multiple members per fax will be returned to the provider and not processed.

Minimum Information Required to Process a Request

Providers must use the Texas Standard Prior Authorization Request Form*, which can be found at Click on Downloadable Forms on the left-hand side, then click Standard Prior Authorization Form or Behavioral Health Authorization Form to download.

The following essential information is required to start the authorization process:

  • Member Name, Member Date of Birth, and Member Medicaid/CHIP ID
  • Requesting Provider’s Name and Requesting Provider’s NPI Number
  • Rendering Provider’s Name and Rendering Provider’s NPI Number
  • Service Requested CPT code, Number of Units Requested, and Dates of Service Requested

Texas Children’s Health Plan may return an incomplete prior authorization request when the form does not contain all of the essential information listed above and request that the provider resubmit the request with all of the appropriate information included. Processing of the authorization will not begin until all essential information is received.

Duplicate Authorization Requests

All prior authorization requests are subject to a duplicate review.

Prior authorization requests that are a duplicate of a previously submitted authorization request will be returned to the provider. The request will be closed as a duplicate request.

If applicable, for denied service requests, the Texas Children’s Health Plan internal appeal process and appropriate external review processes are available to members and providers.

Requests to Close a Pending Authorization

If a provider or member requests to close/withdraw a prior authorization request that is in process and Texas Children’s Health Plan has not made a determination, the provider or member must submit the request to Texas Children’s Health Plan in writing and include the following information:

  • Date of the withdrawal request
  • Person’s name and contact information making the request
  • Reason for the withdrawal of the request

Transition Process

Texas Children’s Health Plan will allow providers a 30-day grace period to comply with these procedures.

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