Provider Alert! Essential Information for Prior Authorization Submission

Date: January 13, 2021
Attention: All Providers

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to remind network providers of the required information for a prior authorization submission.

The Texas Standard Prior Authorization Form* including the following information:

• Member Name
• Member Date of Birth
• Member Medicaid/CHIP Identification Number
• Requesting Provider Name and National Provider Identifier (NPI)
• Servicing Provider Name and NPI
• Requested Service
• Current Procedures Terminology (CPT) Codes Requested
• Number of Units Requested
• Dates of Service

*Standard Prior Authorization Form

An in-network provider signature is no longer required on the authorization form.

How this impacts providers: When Texas Children’s Health Plan (TCHP) receives a request for prior authorization for a Medicaid member under age 21, and the request does not contain complete documentation and/or information TCHP will do the following:

• Return the request to the Medicaid provider with a letter describing the documentation that needs to be

submitted, and

• When possible, TCHP will contact the Medicaid provider by telephone and obtain the information necessary to complete the prior authorization process.
• If the documentation/information is not provided within sixteen (16) business hours of TCHP’s request to the Medicaid provider, TCHP will send a letter to the member explaining that the request cannot be acted upon until the documentation/information is provided. Additionally, a copy of the letter is sent to the Medicaid provider describing the documentation/information that needs to be submitted.
• If the documentation/information is not provided to the TCHP within seven calendar days (7) of its letter to the member, TCHP will send a notice to the member informing the member of its denial of the requested service due to the incomplete documentation/information. At this time, the member has an opportunity to request an appeal through the TCHP’s internal appeals process and the Health and Human Services Commission state fair hearing process.

Next steps for providers: Provider should share these requirements with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.