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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 Authorization - Beacon Health Options

Pharmacy Authorizations - Navitus Health Solutions

Vision Authorizations - National Vision Administrators

 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.  For practitioners who do not have internet or fax access, a copy of the criteria is available by mail. 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

  1. Member Name
  2. Member ID number
  3. Member Date of Birth
  4. Requesting Provider's Name
  5. Requesting Provider's National Provider Identifier (NPI)
  6. Requesting Provider's Tax Identification Number
  7. Servicing Provider's Name
  8. Servicing Provider's National Provider Identifier (NPI)
  9. Servicing Provider's Tax Identification Number
  10. Requesting Provider's Dated Signature and Credentials
  11. For Physical/Occupational/Speech Therapy, Treating Therapist's Dated Signature and Credentials
  12. Supporting Clinical Documentation

Request for Information (RFI Process)

    Cook Children's Health Plan would like to ensure timely processing of all authorizations. Effective 04/01/2021, prior authorization requests with incomplete or missing information for Medicaid Members are processed as follows:

    Cook Children's Health Plan must receive essential information in order to process a prior authorization request. Essential information includes all of the following:

    1. Member name
    2. Member ID number
    3. Member date of birth
    4. Requesting Provider's name
    5. Requesting Provider's National Provider Identifier (NPI)
    6. Requesting Provider's Tax Identification Number
    7. Servicing Provider's name
    8. Servicing Provider's National Provider Identifier (NPI)
    9. Servicing Provider's Tax Identification Number
    10. Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT)
    11. Service requested start and end date(s)
    12. Quantity of service units requested based on the CPT, HCPCS, or CDT requested

    If any essential information is not provided to Cook Children's Health Plan, the request cannot be processed. The request is returned to the requesting provider outlining the missing elements.

    Additionally, the requesting provider should add any supporting clinical documentation he/she feels would be pertinent to prevent further delays in processing. Cook Children's Health Plan must receive sufficient clinical documentation to support medical necessity for a requested service.

    Cook Children's Health Plan will process your request once any missing essential information and/or pertinent supporting clinical information is received.

    If it is determined, upon review, that additional information is needed, a letter is sent to the Member, Requesting and Servicing Provider outlining the information needed. Cook Children's Health Plan must receive the requested information within 3 business days from the date of the letter. Additional information should be submitted to us via our Secure Provider Portal or faxed to 682-885-8402. Please reference the referral number provided on your letter. If the requested information is not received within the specified time frame, Cook Children's Health Plan is required by regulations to make a decision based solely on the information that we have.

    If you wish to have a peer-to-peer discussion with our Medical Director, please contact Cook Children's Health Plan for scheduling by contacting 682-303-8248.

    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.