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Prior Authorization


Use the tool below to search for a valid HCPCS or CPT code.

Prior Authorization Lookup
Service Code:   Date of Service:





For Service codes for which Cook Children's Health Plan does not require prior authorization, it remains the Providers' responsibility to verify that the code is a benefit of Texas Medicaid by utilizing the Texas Medicaid Provider Procedures Manual and the Medicaid Fee Schedule.


How to Submit a Prior Authorization

Behavioral Health Authorizations​

Pharmacy Authorizations

Vision Authorizations

 For Medical Authorization, Cook Children’s Health Plan accepts prior authorization requests via the following methods:

Provider Inquiries may be sent to CCHPPriorauthorizations@cookchildrens.org.  Please reserve this for inquiries only.  We request that this is not utilized for routine prior authorization requests.

Prior Authorization Updates

Determining Medical Necessity

 Cook Children’s Health Plan uses the following criteria resources for determining Medical Necessity:

* These criteria are available to Members, physician's and other professional providers upon request.  Ask to speak with Utilization Management at one of the following numbers to initiate a request:

  • STAR Kids Members: 800-843-0004
  • CHIP and STAR Members: 800-964-2247
  • Providers: 888-243-3312

Prior authorization assistance for Providers

To clarify or obtain assistance with prior authorization requirements you may contact Cook children's Health Plan at 866-243-3312, Monday through Friday from 8:00 a.m. to 5:00 p.m., (excluding holidays).

To clarify or obtain assistance with pharmacy prior authorization requirements you may contact Navitus Health Solutions at 866-333-2757, 24 hours a day, 7 days a week, (Closed Thanksgiving and Christmas Day).

Prior authorization assistance for Members

If you have questions or need help with prior authorization, please call Cook Children's Health Plan. We have staff available to take your call Monday through Friday from 8:00 a.m. to 5:00 p.m., except for state holidays.

STAR Kids Members:
1-844-843-0004
Local-682-885-0004
TTY/TDD-1-844-644-4137
Local-682-885-2138

CHIP/STAR Members:
1-800-964-2247
Local-682-885-2247
TTY/TDD-1-844-644-4137
Local-682-885-2138

Prior Authorization Determination Timeframes

Types of Authorization Requests

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

Severity Type

Turnaround Time

 Routine  Within 3 business days after CCHP receives the request
 Urgent  Within 1 business day after CCHP receives the request
 Inpatient (Concurrent)  Within 1 business day after CCHP receives the request
 Emergent/Life Threatening  Within 1 hour after CCHP receiving the request

Pharmacy Prior Authorization Timeframes

    Our pharmacy vendor, Navitus, will provide a prior authorization decision at the time of the call, when the caller is requesting a Medicaid prior authoriztion and has all the necessary information required to complete the prior authorization review.

    For all others STAR/STAR Kids Medicaid prior authorization requests, Navitus will notify the prescriber's office of a prior authorization denial or approval no later than 24 hours after receipt.

    If Navitus cannot provide a response to the prior authorization request within 24 hours after receipt or the prescriber is not available to make a prior authorization request because it is after the prescriber's office hours and the dispensing pharmacist determines it is an emergency situation, Navitus will allow the pharmacy to dispense a 72-hour supply of the drug. This requirement applies to drugs which can be filled as a 72-hour supply.

Information Required for Prior Authorization Process

  • Member Name
  • Member Date of Birth
  • Member Medicaid/CHIP Identification Number
  • Requesting Provider Name and NPI
  • Servicing Provider Name, NPI and TPI
  • Indication of Acute, Urgent or Routine
  • Current Procedures Terminology (CPT) and/or Healthcare Common Procedure Coding System (HCPCS) Requested
  • Required Modifiers
  • Number of Units
  • Unit Type (procedure, unit or visits)
  • Date(s) of Service
  • Requesting Provider's Dated Signature and Credentials
  • For Physical/Occupational/Speech Therapy, Treating Therapist's Dated Signature and Credentials
  • Supporting Clinical Documentation
 

Request for Information (RFI Process)

When Cook Children's Health Plan receives a request for prior authorization for a Medicaid Member under age 21, and the request does not contain complete documentation and/or information, CCHP will:

  • Contact the Requesting and Servicing with a letter describing the documentation that needs to be submitted. The information must be submitted within sixteen (16) business hours of the request for information.

  • If the documentation/information is not provided within sixteen (16) business hours of CCHP's request, CCHP will send a letter to the Member explaining that the request cannot be acted upon until the documentation/information is provided, along with a copy of the letter sent to the Medicaid provider describing the documentation/information that needs to be submitted.
  • If the documentation/information is not provided to CCHP within seven (7) calendar days of its letter to the Member, CCHP will send a notice to the Member informing the Member of its denial of the requested service due to the incomplete documentation/information, and providing the Member an opportunity to request an appeal through the CCHP's internal appeal process and the Health and Human Services Commission State Fair Hearing process.

Providers must submit complete prior authorization requests in order for authorization to be processed as outlined.

Prior Authorization Guidelines

Documents and Tools

If you have any questions please call Provider Services at 1-888-243-3312 Monday through Friday from 8 a.m. to 5 p.m. or Contact us here

     

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    Please Note: Authorization not required response is not a guarantee of payment. Payment is subject to the member’s eligibility and benefits on the date of service. Please verify benefit limitations per the Texas Medicaid Provider Procedures Manual. Please call Care Management at 888-243-3312 (toll free) if you have any questions.