Prior Authorization Information

External Medical Review Provider Training from Health and Human Services is available here for all providers. For more information on External Medical Review click here.

Authorizations

Prior Authorization Dates of Service Calculator from TMHP

Providers should use the calculator to calculate the DOS that must be applied to the prior authorization form/prior authorization request.

Dates of service (DOS) calculator

Source: https://www.tmhp.com/topics/prior-authorization

Prior Authorization Fax Lines

Medical Inpatient Admissions and Discharge Notifications (notification that a member discharged) - 832-825-8462 or Toll-Free 844-663-7071
Medical Services Fax Line - 832-825-8760 or Toll-Free 1-844-473-6860
Behavioral Health Services Fax Line - 832-825-8767 or Toll-Free 1-844-291-7505
LTSS and Private Duty Nursing Fax Line - 346-232-4757 or Toll-Free 1-844-248-1567
Hospital Discharge Authorizations Fax Line (for members who are hospitalized at the time of the request and services or equipment that are necessary for care of the member immediately after discharge) - Toll-Free 866-839-9879

Contact Us

Please contact us if you have questions or need assistance with prior authorizations.

Providers: 1-800-731-8527

Providers may also reach out to their Provider Relations Liaison, contact information is available here.

For information on hours of operation and more details, please click here. One of our representatives will contact you within two hours or within one business day for calls received on nights, weekends and holidays.

Utilization Management Hours of Operation:

Monday through Friday 8 a.m. to 5 p.m. CST

Pharmacy Benefit (Retail Drug) Prior Authorization

For medication authorization inquiries, providers and pharmacies should contact the Navitus Prior Authorization Department at 1-877-908-6023. Requests for appeals should be directed to Texas Children’s Health Plan.

Timeline for Prior Authorization requests made with Navitus:

If the prescriber calls the prior authorization call center, the approval or denial decision occurs immediately
For routine and urgent requests, the approval or denial is made within 24 hours
If a prior authorization is not received within 24 hours, or the provider is not available to make request, the pharmacy can give a 72 hour emergency supply if the pharmacist determines it is an emergent situation. Source: https://txstarchip.navitus.com/

For additional information regarding medication related pharmacy prior authorizations, see links below.

Members:

CHIP 1-866-959-6555
STAR 1-866-959-2555
STAR Kids 1-800-659-5764

Our Member Services team is ready to take your call from 8 a.m. to 5 p.m., Monday through Friday. After hours, on weekends and holidays, our answering service is ready to help you and/or take your messages. A Member Service Advocate will return your call the next business day.

We speak English or Spanish. We also have interpreters available by phone who speak 140 different languages.

Texas Children’s Health Plan offers TDD.TTY services for deaf, hard of hearing or speech impaired members and providers. For TDD assistance, please call 1-800-735-2989 or 7-1-1.

Prior Authorization Determinations

The Utilization Management department processes service requests in accordance with the clinical immediacy of the requested services.

Authorization | Turnaround Time

Routine | Within 3 business days after receipt of request

Urgent | Within 1 business day after receipt of request

Inpatient | Within 1 business day after receipt of request

TCHP does not require prior authorization for Emergency Medical Conditions or Emergency Behavioral Health Conditions

Within one hour for post-hospitalization or life-threatening conditions, TCHP does not require prior authorization.

Post hospital discharge services | Within one business day

Prior Authorization Guidelines

Below you will find all of the Prior Authorization Guidelines. If you wish to open the following forms, you must have Adobe Acrobat Reader installed on your computer. To download a form, right click on one of the links below and select "Save Target As."

Providers should reference the guidelines listed below for a specific service. Each guideline lists the required documentation and forms that must accompany an authorization request.

Download a free copy of Adobe Acrobat Reader, click here.