Provider Alert! Reminders: Prior Authorization Requirements and Qualifications for Urgent Requests

Date: May 5, 2021

Attention: All Providers

Reminders: Prior Authorization Requirements and Qualifications for Urgent Requests

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 prior authorization requirements and qualifications for urgent requests.

How this impacts providers: The Utilization Management Department requires a complete prior authorization request in order to properly streamline authorizations and limit the number of unnecessary denials.

Here is a list of the requirements for all requests:
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 (Rendering) Provider Name and NPI
• Requested Service
• Current Procedures Terminology (CPT) Codes Requested
• Number of Units Requested
• Dates of Service

Supporting Clinical Documentation:

When Texas Children’s Health Plan (TCHP) receives a request for prior authorization for a service for a

Medicaid member, and the request does not provide enough clinical information or supporting

documentation for us to determine if these services are medically necessary TCHP will:

• Send the Medicaid provider a letter describing the specific 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

• Send the member a copy of the letter that was sent to the provider

The provider will need to submit the requested information by the end of the day on the third business day after the date of the TCHP letter.

If Texas Children’s Health Plan does not receive the requested information or documentation by this date, we will make a decision regarding the requested services based on the information previously received.

For therapy requests, items to submit with the authorization requests include the following:

• Current and past test scores
• A signed plan of care (or documentation missing signature due to COVID)
• Therapy attendance and home exercise program participation
• Current well child information
• Change of therapy provider letter when indicated

For urgent requests, Clinical reason for urgency should be listed per the prior authorization form.

Valid examples for an urgent request include: urgent injury, urgent procedure requested due to clinical need

Examples of NON-URGENT requests: routine therapy, routine scheduled follow up visits/procedures, ongoing DME services.

For appeals: Qualifications for an expedited appeal of an adverse determination: When taking the time for a standard resolution could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain or regain maximum function.

TCHP will review requests for expedited appeals, and if standard resolution will not seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain or regain maximum function an expedited appeal will not be granted. The appeal will be transferred to the timeframe for standard resolution (30 days) and the member and provider will receive written notification

Next steps for providers: Network providers must adhere to the prior authorization requirements and qualifications for urgent requests as outlined in this provider alert and should share this communication with their staff. For any questions, providers should contact their provider relations liaison. The contact information is available here.

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