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. All out of network services require prior authorization (except STAR and STAR Kids family planning, Texas Health Step services performed by those with valid Texas Health Steps provider identifier, emergency care and physicians services for uncomplicated deliveries, and services provided by an Indian Health Care provider enrolled as a FQHC).
Behavioral Health Authorizations - 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 CCHPPriorauthorization@cookchildrens.org
Please reserve this for inquiries only. We request that this is not utilized for routine prior authorization requests.
Cook Children's Health Plan uses the following criteria resources for determining Medical Necessity:
*These criteria are available to Members, physicians'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 Managment at one of the following mumbers to initiate a request:
To clarify or obtain assistance with prior authorization requirements you may contact Cook Children's Health Plan at 888-243-3312, 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).
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:
Types of authorization requests
The Utilization Management department processes service requests in accordance with the clinical immediacy of the requested services.
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.
Providers must submit complete prior authorization requests in order for authorization to be processed as outlined.
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:
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 documenation 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.
Cook Children’s Health Plan endorses nationally recognized, evidence-based clinical practice guidelines that are based on needs and opportunities for improvement. Clinical practice guidelines are reviewed every two years, or more frequently if national guidelines change within the two year period. Cook Children’s Health Plan currently recommends the following clinical practice guidelines:
Beacon Health Options, our Behavioral Health vendor, also endorses a number of clinical practice guidelines regarding behavioral health. These clinical practice guidelines are also updated every two years, or sooner if necessary, and may be located at the following link: https://www.beaconhealthoptions.com/providers/beacon/handbook/clinical-practice-guidelines/