- DentaQuest
- MCNA
- FCL Dental
- Community Health Choice secure Provider portal
- Fax: 713.295.2286
- Community Health Choice secure Provider portal
- Fax: 713.576.0932 (Inpatient)
- Fax: 713.576.0931 (Outpatient)
- Pharmacy Authorizations
- Vision Authorizations
- Dental (under 21)
- DentaQuest
- MCNA
- FCL Dental
- Community Health Choice secure provider portal
- Fax: 713.295.2283
- Community Health Choice secure provider portal
- Fax: 713.295.7016
- Community Health Choice secure provider portal
- Fax: 713.576.0932 (Inpatient)
- Fax: 713.576.0931 (Outpatient)
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information to initiate the prior authorization review process:
- Member’s name
- Member date of birth
- Member number or Medicaid number
- Requesting provider’s name
- Requesting provider’s National Provider Identifier (NPI)
- Rendering provider’s name
- Rendering provider’s National Provider Identifier (NPI)
- Rendering provider’s Tax identification number
- Service requested:
- Current Procedural Terminology (CPT),
- Healthcare Common Procedure Coding System (HCPCS), or
- Current Dental Terminology (CDT)
Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted.
Supporting Clinical Documentation
Supporting documentation necessary to obtain prior authorization for a specified service includes a completed TSPA form, current clinical records that support the requested service, and any other documentation as per the TMPPM, (ex. Sterilization Consent Form, The Criteria for Dental Therapy under General Anesthesia Form, etc.)
Click here for the Clinical Practice Guidelines
Click here for a list of requirements for Transplants.
Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:
- Peer-reviewed, published medical journals.
- Evidence-based consensus statements
- Practice guidelines/standards from professionally recognized health care organizations
- Evidence-based research reviews of a particular topic/technology
Our MRGs are used when the Texas Medicaid Provider Procedures Manual (TMPPM) does not have any clinical criteria for certain services. Our review guidelines are applied in the following order:
- State/Federal guidelines and Contract Requirements
- TMPPM
- MRGs
- InterQual
Although some MRGs may assist with coverage decisions, recommendations contained in the MRGs are not a guarantee of coverage. Community’s MRGs are available upon request.
Lack of Information
When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
- Community will notify the Member by letter that an authorization request was received, but cannot be acted upon until Community receives the missing documentation/information from the requesting Provider. The letter will include the following information:
- A statement that Community has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- An applicable timeline for the provider to submit the missing information.
- Information on the manner through which a provider may contact Community.
Start of Care (SOC) exceptions will be approved when a Provider is able to submit additional information sufficient to classify a request as complete and the MCO has determined that requested services meet medical necessity from the SOC date.
Service Initial Authorization Re-certification of Authorization Therapy (PT/OT/ST) Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated. Requests received after the five-business-day period will be denied for dates of service that occurred before the date that the PA request was received. Requests for recertification services received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. Should not be received >30 days before expiration of previous authorization. Private Duty Nursing Initial requests must be submitted within three business days of the SOC date. A recertification request must be submitted at least 7 calendar days before, but no more than 30 days before, a current authorization period will expire. DME Prior authorization must be obtained for some supplies and most DME within three business days of the DOS. Prior authorization must be obtained for some supplies and most DME within three business days of the DOS. Community issues a determination within the following timeframes according to state regulatory requirements.
Prospective Review
- Emergency Medical or Emergency Behavioral Conditions do not require prior authorization
- Urgent – As soon as possible based on the clinical situation, but no later than one business day from receipt of a request for a Utilization Management (UM) determination
- Routine – Within three business days from the receipt of a request for a UM determination
- Inpatient – Within one business day from the receipt of a request for a UM determination
- Post-hospitalization or life-threatening conditions – within one hour from the receipt of a request
Concurrent Review
Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.
Retrospective Review
Based on the Retrospective Review Policy for authorizations, if certain conditions are met Community will issue a determination, Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.
Pharmacy
- Urgent – if prescribing Provider calls Community, Community will provide prior authorization approval or denial immediately.
- Routine – Community will notify the prescribing Provider of prior authorization denial or approval no later than 24 hours after receipt.
- If Community cannot provide response to a prior authorization request within 24 hours after receipt or the prescriber is unavailable to make request (after-hours) and dispensing pharmacist determines it is an emergency, Community will allow the pharmacy to dispense a 72-hour supply of the drug.
Community will deny a claim if the Provider does not obtain an authorization prior to providing services to a Member. In no event will a Member be financially responsible for payments for such services, except for those Member expenses that are required under the Member’s specific benefit plan/program.
Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting. Discharge planning may include, but is not limited to the following:
- Home Health Services
- Skilled Nurse Visits
- Physical Therapy
- Occupational Therapy
- Speech Therapy
Please submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility.
If a Member is discharged during non-business hours and/or the weekend, Providers should submit discharge planning requests the following business day. All discharge authorizations are reviewed for evaluation and initial treatment.
For a continuation of treatment and services after discharge authorization, new physician orders from the Member’s PCP or Specialist are required. These requests must be submitted to the appropriate fax number for prior authorization requests.
- Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
- Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
- For Members transitioning from an Acute hospital to LTAC or SNF:
- Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
- Fax request (PA form and discharge orders with clinical information to: 713.848.6940
All discharge planning authorization requests follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.
If an authorization request does not meet medical necessity, a Medical Director will review the request.
Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.
To request a Peer-to-Peer discussion, please call 713.295.2319.
Click here to return to the Member site.
Haga clic aquí para volver al sitio de miembros.
Para la versión en español, haga clic aquí.
What is a prior authorization?
STAR+PLUS Prior authorization verifies whether medical treatment that is not an emergency is medically necessary. It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Community Health Choice will also verify if the Member has benefits.
Prior authorization is sometimes called pre-certification or pre-notification.
Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Community must still process a Provider’s claim to determine if payment will be made. The claim is processed according to:
- Eligibility;
- Contract limitations;
- Benefit coverage guidelines;
- Applicable State or Federal requirements;
- National Correct Coding Initiative (NCCI) edits;
- Texas Medicaid Provider Procedures Manual (TMPPM); and
- Other program requirements, as applicable.
Please contact us if you have questions or need assistance with prior authorizations.
STAR+PLUS Hours
8:00 a.m. – 5:00 p.m., Monday – Friday, excluding state-approved holidays.Phone
Local: 713.295.2300 Toll Free: 1.888.495.2850Pharmacy Prior Authorization Assistance
1.877.908.6023Please contact us if you have questions or need assistance with medical/pharmacy prior authorizations.
Local: 713.295.2300 Toll Free: 1.888.435.2850
Number for Hearing Impaired TTY 7-1-1
8:00 a.m. – 5:00 p.m., Monday – Friday, excluding state-approved holidays.
Click here to view the 2024 catalog.
- Important updates to the Synagis Standard Prior Authorization Request
November 17, 2023
Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.
Prior Authorization Submission
- Pharmacy Authorizations
- Vision Authorizations
- Dental (under 21)
- DentaQuest
- MCNA
- FCL Dental
- Community Health Choice secure Provider portal
- Fax: 713.295.2286
- Community Health Choice secure Provider portal
- Fax: 713.576.0932 (Inpatient)
- Fax: 713.576.0931 (Outpatient)
- LTSS Service Coordination Prior Authorization:
- Fax: 713-848-6958
- DentaQuest
- MCNA
- FCL Dental
- Community Health Choice secure provider portal
- Fax: 713.848.6957
- Community Health Choice secure provider portal
- Fax: 713.295.7016
- Community Health Choice secure provider portal
- Fax: 713.576.0852 (Inpatient)
- Fax: 713.576.0852 (Outpatient)
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information to initiate the prior authorization review process:
- Member’s name
- Member date of birth
- Member number or Medicaid number
- Requesting provider’s name
- Requesting provider’s National Provider Identifier (NPI)
- Rendering provider’s name
- Rendering provider’s National Provider Identifier (NPI)
- Rendering provider’s Tax identification number
- Service requested:
- Current Procedural Terminology (CPT),
- Healthcare Common Procedure Coding System (HCPCS), or
- Current Dental Terminology (CDT)
Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted.
Supporting Clinical Documentation
Supporting documentation necessary to obtain prior authorization for a specified service includes a completed TSPA form, current clinical records that support the requested service, and any other documentation as per the TMPPM, (ex. Sterilization Consent Form, The Criteria for Dental Therapy under General Anesthesia Form, etc.)
Click here for the Clinical Practice Guidelines
Click here for a list of requirements for Transplants.
Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:
- Peer-reviewed, published medical journals.
- Evidence-based consensus statements
- Practice guidelines/standards from professionally recognized health care organizations
- Evidence-based research reviews of a particular topic/technology
Our MRGs are used when the Texas Medicaid Provider Procedures Manual (TMPPM) does not have any clinical criteria for certain services. Our review guidelines are applied in the following order:
- State/Federal guidelines and Contract Requirements
- TMPPM
- MRGs
- InterQual
Although some MRGs may assist with coverage decisions, recommendations contained in the MRGs are not a guarantee of coverage. Community’s MRGs are available upon request.
Lack of Information
When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
- Community will notify the Member by letter that an authorization request was received, but cannot be acted upon until Community receives the missing documentation/information from the requesting Provider. The letter will include the following information:
- A statement that Community has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- An applicable timeline for the provider to submit the missing information.
- Information on the manner through which a provider may contact Community.
Start of Care (SOC) exceptions will be approved when a Provider is able to submit additional information sufficient to classify a request as complete and the MCO has determined that requested services meet medical necessity from the SOC date.
Service Initial Authorization Re-certification of Authorization Therapy (PT/OT/ST) Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated. Requests received after the five-business-day period will be denied for dates of service that occurred before the date that the PA request was received. Requests for recertification services received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. Should not be received >30 days before expiration of previous authorization. Private Duty Nursing Initial requests must be submitted within three business days of the SOC date. A recertification request must be submitted at least 7 calendar days before, but no more than 30 days before, a current authorization period will expire. DME Prior authorization must be obtained for some supplies and most DME within three business days of the DOS. Prior authorization must be obtained for some supplies and most DME within three business days of the DOS. Community issues a determination within the following timeframes according to state regulatory requirements.
Prospective Review
- Emergency Medical or Emergency Behavioral Conditions do not require prior authorization
- Urgent – As soon as possible based on the clinical situation, but no later than one business day from receipt of a request for a Utilization Management (UM) determination
- Routine – Within three business days from the receipt of a request for a UM determination
- Inpatient – Within one business day from the receipt of a request for a UM determination
- Post-hospitalization or life-threatening conditions – within one hour from the receipt of a request
Concurrent Review
Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.
Retrospective Review
Based on the Retrospective Review Policy for authorizations, if certain conditions are met Community will issue a determination, Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.
Pharmacy
- Urgent – if prescribing Provider calls Community, Community will provide prior authorization approval or denial immediately.
- Routine – Community will notify the prescribing Provider of prior authorization denial or approval no later than 24 hours after receipt.
- If Community cannot provide response to a prior authorization request within 24 hours after receipt or the prescriber is unavailable to make request (after-hours) and dispensing pharmacist determines it is an emergency, Community will allow the pharmacy to dispense a 72-hour supply of the drug.
Community will deny a claim if the Provider does not obtain an authorization prior to providing services to a Member. In no event will a Member be financially responsible for payments for such services, except for those Member expenses that are required under the Member’s specific benefit plan/program.
Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting. Discharge planning may include, but is not limited to the following:
- Home Health Services
- Skilled Nurse Visits
- Physical Therapy
- Occupational Therapy
- Speech Therapy
Please submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility.
If a Member is discharged during non-business hours and/or the weekend, Providers should submit discharge planning requests the following business day. All discharge authorizations are reviewed for evaluation and initial treatment.
For a continuation of treatment and services after discharge authorization, new physician orders from the Member’s PCP or Specialist are required. These requests must be submitted to the appropriate fax number for prior authorization requests.
- Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
- Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
- For Members transitioning from an Acute hospital to LTAC or SNF:
- Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
- Fax request (PA form and discharge orders with clinical information to: 713.848.6940
All discharge planning authorization requests follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.
If an authorization request does not meet medical necessity, a Medical Director will review the request.
Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.
To request a Peer-to-Peer discussion, please call 713.295.2319.
Click here to return to the Member site.
Haga clic aquí para volver al sitio de miembros.
Para la versión en español, haga clic aquí.
What is a prior authorization?
(Medicaid) Prior authorization verifies whether medical treatment that is not an emergency is medically necessary. It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Community Health Choice will also verify if the Member has benefits.
Prior authorization is sometimes called pre-certification or pre-notification.
Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Community must still process a Provider’s claim to determine if payment will be made. The claim is processed according to:
- Eligibility;
- Contract limitations;
- Benefit coverage guidelines;
- Applicable State or Federal requirements;
- National Correct Coding Initiative (NCCI) edits;
- Texas Medicaid Provider Procedures Manual (TMPPM); and
- Other program requirements, as applicable.
Please contact us if you have questions or need assistance with prior authorizations.
Medicaid Hours
Monday – Friday, 8:00 a.m. – 5:00 p.m.
Saturday/Sunday/Holidays, 9:00 a.m. – 12:00 p.m.CHIP Hours
Monday – Friday, 6:00 a.m. – 6:00 p.m.
Saturday/Sunday/Holidays, 9:00 a.m. – 12:00 p.m.Phone
713.295.2295 or toll free 1.888.760.2600Pharmacy Prior Authorization Assistance
1.877.908.6023Please contact us if you have questions or need assistance with medical/pharmacy prior authorizations.
Local: 713.295.2294
Toll-Free: 1.888.760.2600
TDD Number for Hearing Impaired 7-1-1Monday through Friday (excluding State-approved holidays)
8:00 a.m. to 6:00 p.m.
Click here to view the June 2024 catalog
Click here to view the April 2024 catalog
Click here to view the 2024 catalog.
Click here to view the 2023 catalog.
Click here to view the 2022 catalog.
- Prior authorization updates April 8, 2024
- Important updates to the Synagis Standard Prior Authorization Request
November 17, 2023
Click here to review the Prior Authorization Annual Review Report.
Click here to review the Prior Authorization Change Log.
Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.
Prior Authorization Submission
- Pharmacy Authorizations
- Vision Authorizations
- Dental (under 21)
- DentaQuest
- MCNA
- FCL Dental
- Community Health Choice secure Provider portal
- Fax: 713.295.2286
- Community Health Choice secure Provider portal
- Fax: 713.576.0932 (Inpatient)
- Fax: 713.576.0931 (Outpatient)
- Pharmacy Authorizations
- Vision Authorizations
- Dental (under 21)
- DentaQuest
- MCNA
- FCL Dental
- Community Health Choice secure provider portal
- Fax: 713.295.2283
- Community Health Choice secure provider portal
- Fax: 713.295.7016
- Community Health Choice secure provider portal
- Fax: 713.576.0932 (Inpatient)
- Fax: 713.576.0931 (Outpatient)
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information to initiate the prior authorization review process:
- Member’s name
- Member date of birth
- Member number or Medicaid number
- Requesting provider’s name
- Requesting provider’s National Provider Identifier (NPI)
- Rendering provider’s name
- Rendering provider’s National Provider Identifier (NPI)
- Rendering provider’s Tax identification number
- Service requested:
- Current Procedural Terminology (CPT),
- Healthcare Common Procedure Coding System (HCPCS), or
- Current Dental Terminology (CDT)
Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted.
Supporting Clinical Documentation
Supporting documentation necessary to obtain prior authorization for a specified service includes a completed TSPA form, current clinical records that support the requested service, and any other documentation as per the TMPPM, (ex. Sterilization Consent Form, The Criteria for Dental Therapy under General Anesthesia Form, etc.)
Click here for the Clinical Practice Guidelines
Click here for a list of requirements for Transplants.
Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:
- Peer-reviewed, published medical journals.
- Evidence-based consensus statements
- Practice guidelines/standards from professionally recognized health care organizations
- Evidence-based research reviews of a particular topic/technology
Our MRGs are used when the Texas Medicaid Provider Procedures Manual (TMPPM) does not have any clinical criteria for certain services. Our review guidelines are applied in the following order:
- State/Federal guidelines and Contract Requirements
- TMPPM
- MRGs
- InterQual
Although some MRGs may assist with coverage decisions, recommendations contained in the MRGs are not a guarantee of coverage. Community’s MRGs are available upon request.
Lack of Information
When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
- Community will notify the Member by letter that an authorization request was received, but cannot be acted upon until Community receives the missing documentation/information from the requesting Provider. The letter will include the following information:
- A statement that Community has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- An applicable timeline for the provider to submit the missing information.
- Information on the manner through which a provider may contact Community.
Start of Care (SOC) exceptions will be approved when a Provider is able to submit additional information sufficient to classify a request as complete and the MCO has determined that requested services meet medical necessity from the SOC date.
Service Initial Authorization Re-certification of Authorization Therapy (PT/OT/ST) Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated. Requests received after the five-business-day period will be denied for dates of service that occurred before the date that the PA request was received. Requests for recertification services received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. Should not be received >30 days before expiration of previous authorization. Private Duty Nursing Initial requests must be submitted within three business days of the SOC date. A recertification request must be submitted at least 7 calendar days before, but no more than 30 days before, a current authorization period will expire. DME Prior authorization must be obtained for some supplies and most DME within three business days of the DOS. Prior authorization must be obtained for some supplies and most DME within three business days of the DOS. Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include 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
- In Network Requesting Provider’s Dated Signature
To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.
Community issues a determination within the following timeframes according to state regulatory requirements.
Prospective Review
- Emergency Medical or Emergency Behavioral Conditions do not require prior authorization
- Urgent – As soon as possible based on the clinical situation, but no later than one business day from receipt of a request for a Utilization Management (UM) determination
- Routine – Within three business days from the receipt of a request for a UM determination
- Inpatient – Within one business day from the receipt of a request for a UM determination
- Post-hospitalization or life-threatening conditions – within one hour from the receipt of a request
Concurrent Review
Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.
Retrospective Review
Based on the Retrospective Review Policy for authorizations, if certain conditions are met Community will issue a determination, Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.
Pharmacy
- Urgent – if prescribing Provider calls Community, Community will provide prior authorization approval or denial immediately.
- Routine – Community will notify the prescribing Provider of prior authorization denial or approval no later than 24 hours after receipt.
- If Community cannot provide response to a prior authorization request within 24 hours after receipt or the prescriber is unavailable to make request (after-hours) and dispensing pharmacist determines it is an emergency, Community will allow the pharmacy to dispense a 72-hour supply of the drug.
Community will deny a claim if the Provider does not obtain an authorization prior to providing services to a Member. In no event will a Member be financially responsible for payments for such services, except for those Member expenses that are required under the Member’s specific benefit plan/program.
Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting. Discharge planning may include, but is not limited to the following:
- Home Health Services
- Skilled Nurse Visits
- Physical Therapy
- Occupational Therapy
- Speech Therapy
Please submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility.
If a Member is discharged during non-business hours and/or the weekend, Providers should submit discharge planning requests the following business day. All discharge authorizations are reviewed for evaluation and initial treatment.
For a continuation of treatment and services after discharge authorization, new physician orders from the Member’s PCP or Specialist are required. These requests must be submitted to the appropriate fax number for prior authorization requests.
- Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
- Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
- For Members transitioning from an Acute hospital to LTAC or SNF:
- Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
- Fax request (PA form and discharge orders with clinical information to: 713.848.6940
All discharge planning authorization requests follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.
If an authorization request does not meet medical necessity, a Medical Director will review the request.
Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.
To request a Peer-to-Peer discussion, please call 713.295.2319.
Para la versión en español, haga clic aquí.
What is a prior authorization?
(Medicare) Prior authorization (sometimes referred to as pre-certification or pre-notification) determines whether non-emergent medical treatment is medically necessary, is compatible with the diagnosis, if the Member has benefits, and if the requested services are to be provided in the appropriate setting.
Prior authorization is not a guarantee of payment. Regardless of whether a Provider obtained the required prior authorization, Community Health Choice must process a Provider’s claim according to eligibility, contract limitations, benefit coverage guidelines, applicable State or Federal requirements, National Correct Coding Initiative (NCCI) edits, Texas Medicaid Provider Procedures Manual (TMPPM) and other program requirements, as applicable.
Please contact us if you have questions or need assistance with prior authorizations.
Monday – Friday
8:00 a.m. – 5:00 p.m.On certain holidays, calls will be handled by our automated phone system.
Phone
713.295.5007 or 1.833.276.8306Toll-Free: 1.833.276.8306
TDD Number for Hearing Impaired 7-1-1Click here to view the October 2024 catalog
Click here to view the June 2024 catalog
Click here to view the May 1, 2024 catalog
Click here to view the April 1, 2024 catalog
Click here to view the 2024 catalog
Click here to view the 2023 catalog
- Prior authorization updates August 22, 2024
- Prior authorization updates April 8, 2024
Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.
- Pharmacy Authorizations
- Vision Authorizations
- Dental (over 21)
- FCL Dental
- Community Health Choice secure provider portal
- Fax: 713.295.7059
- Community Health Choice secure provider portal
- Fax: 713.576.0932 (Inpatient)
- Fax: 713.576.0939 (Outpatient)
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include 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
- In Network Requesting Provider’s Dated Signature
For Transplant Prior Authorization Requests and Clinical Submission, Community accepts prior authorization requests via the following methods:
- Community Health Choice secure provider portal
- Fax: 713.295.7016
Click here for a list of requirements for Transplants.
Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:
- Peer-reviewed, published medical journals.
- Evidence-based consensus statements
- Practice guidelines/standards from professionally recognized health care organizations
- Evidence-based research reviews of a particular topic/technology
Our MRGs are used when the Texas Medicaid Provider Procedures Manual (TMPPM) does not have any clinical criteria for certain services. Our review guidelines are applied in the following order:
- State/Federal guidelines and Contract Requirements
- TMPPM
- MRGs
- InterQual
To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.
Community issues a determination within the following timeframes according to state regulatory requirements.
Prospective Review
- Urgent
As soon as possible based on the clinical situation, but no later than 72 hours from receipt of a request for a Utilization Management (UM) determination - Routine
Within 14 calendar days from the receipt of a request for a UM determination - Inpatient
Within 24 hours from the receipt of a request for a UM determination
Concurrent Review
Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.
Retrospective Review
Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.
Community will administratively deny a claim if the Provider does not obtain an authorization prior to rendering services to a Member. In no event will a Member be financially responsible for payments arising for such services, except for applicable Member expenses as may be required under a benefit plan/program.
Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting. Discharge planning may include, but not limited to the following:
- Home Health Services
- Skilled Nurse Visits
- Physical Therapy
- Occupational Therapy
- Speech Therapy
Please ensure to submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility.
If a Member is discharged during non-business hours and/or weekend, Providers should submit discharge planning requests the following business day. If necessary, all discharge authorizations will be reviewed for evaluation and initial treatment.
For a continuation of treatment and services after discharge authorization, new physician orders from Member’s PCP or Specialist will be required. These requests must be submitted to the appropriate fax number for prior authorization requests.
- Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
- Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
- For members transitioning from an Acute hospital to LTAC or SNF:
- Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
- Fax request (PA form and discharge orders with clinical information to: 713.848.6940
All discharge planning authorization requests will follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.
If an authorization request does not meet medical necessity, a Medical Director will review the request.
Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.
To request a Peer-to-Peer discussion, please call 713.295.2319.
