Utilization Management (Prior Authorizations)

Utilization management is at the heart of how we help members continue to access the right care, at the right place and at the right time. In this section, we will review a type of utilization management review - prior authorizations.

How to Submit a Prior Authorization

Prior authorization requests are initiated by providers by either phone or faxing the applicable form below to the intake department:

Prior Authorization Forms

• Private Duty Nurse (PDN) Initial Request Long Term Services and Support (LTSS) Authorization Request Checklist
  
• Private Duty Nurse (PDN) Recertification and Revision Request Long Term Services and Support (LTSS) Authorization Request Checklist
• Request for Prior Authorization – Acute
  
• Request for Prior Authorization – Long Term Services and Supports (LTSS)
• Texas Standard Prior Authorization Request Form for Health Care Services
• Synagis Standard Prior Authorization Addendum (Medicaid)
• Process for Standard Prior Authorization - if prior authorization information is incomplete or insufficient.
• Applied Behavioral Analysis (ABA) Form
• Applied Behavioral Health Prior Authorization Requirement Checklist

Behavioral Health Prior Authorization Forms

• Substance Use Residential Services Form
• Behavioral Health Prior Authorization Checklist
  

Court Ordered Services - Providers are required to submit a copy of the court order to initiate the authorization process. Court Orders can be submitted via fax 1-888-530-9809.

Provider Utilization Management Hours and Contact Information

Monday – Friday from 8:00 a.m. to 5:00 p.m. central time

• STAR and CHIP intake phone number: 1-877-560-8055
• STAR and CHIP intake fax number: 1-855-653-8129
• STAR Kids intake phone number: 1-877-784-6802
• STAR Kids intake fax number: 1-866-644-5456
• Behavioral Health Fax number: 1-888-530-9809

Member Utilization Management Hours and Contact Information

Monday – Friday from 8:00 a.m. to 5:00 p.m. central time

• STAR and CHIP Service Coordination phone number: 1-877-214-5630 (TTY 711)
• STAR Kids Service Coordination phone number: 1-877-301-4394 (TTY 711)

If your provider needs to contact us, he or she may call the Provider Service Hotline number: 1-877-784-6802.

Have Questions?

If you have questions about an authorization, need additional assistance or would like to obtain a copy of the utilization management criteria used in the decision-making process, contact the Utilization Management department using the contact info above.

Provider Feedback

For feedback regarding Prior Authorization List changes please contact BCBSTX at TX_Medicaid_UM_Feedback@BCBSTX.com.

Helpful Tips When Contacting Utilization Management

Please have the following required information available when calling the intake department:

• Member name
• Member identification number or Medicaid number
• Member date of birth
• Requesting provider name and national provider identifier (NPI)
• Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) or Current Dental Terminology (CDT)
• Service requested start and end date(s)
• Quantity of service units requested based on the CPT, HCPCS or CDT requested

Other information used to process requests include:

• Diagnosis code(s)
• Primary care physician, specialist and/or facility names
• Clinical justification for request
• Treatment and discharge plans (if known)

Timeframes for Prior Authorization

• Concurrent hospitalization decisions – one business day
• Post stabilization or life-threatening conditions – within one hour
• Emergency medical and emergency behavioral health conditions do not require prior authorization; if member is admitted to the hospital, notification is required within one business day
• For a member who is hospitalized at the time of the request, notification is required within one business day of receiving the request for services or equipment that will be necessary for the care of the member immediately after discharge, including if the request is submitted by an out-of-network provider, provider of acute care inpatient services or a member
• All other prior authorization requests – within three business days after receipt

Pharmacy Prior Authorization

Pharmacy benefits are determined by Medicaid/CHIP Vendor Drug Program (VDP) and are administered by BCBSTX. This plan goes by a list of preferred drugs. The Drug List (also called a formulary) is a list showing the drugs that can be covered by the plan.

How to submit a pharmacy prior authorization request

• Submit online requests
• Call 1-855-457-0407 (STAR and CHIP) or 1-855-457-1200 (STAR Kids)
• Fax in completed forms at 1-877-243-6930. View Prescription Drug Forms

Pharmacy Prior Authorization Timeframe

Prior Authorization request received by Prime Therapeutics are date stamped and timeframes to process prior authorization:

• STAR and STAR Kids – 24 hours
• CHIP – three days (Business Days)

• If the prescriber’s office calls the BCBSTX prior authorization call center, we must provide prior authorization approval or denial immediately
• For all other prior authorization requests, we must notify the prescriber’s office of a prior authorization denial or approval no later than 24 hours after receipt
• If BCBSTX 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 dispense pharmacist determines it is an emergency situation, BCBSTX must allow the pharmacy to dispense a 72-hour emergency supply of medication.

For more information about our pharmacy program, visit our Pharmacy page

Prior Authorization Lists and Reports

Refer to the following for services and/or procedure codes that may require prior authorization:

Prior Authorization Requirement List

• Effective 07/01/2024
• Effective 05/01/2024 - 06/30/2024
• Effective 04/01/2024 - 04/30/2024 (*Magellan Behavioral Health Service as Administrator ceases)
• Effective 01/01/2024 - 03/31/2024
• Effective 10/01/2023 - 12/31/2023
• Effective 07/01/2023 - 09/30/2023
• Effective 04/01/2023 - 06/30/2023
• Effective 01/01/2023 - 03/31/2023
  
• Effective 07/01/2022 - 12/31/2022
• Effective 04/01/2022 - 06/30/2022
• Effective 01/01/2022 - 03/31/2022

Prior Authorization Code Grid

• Effective 07/01/2024
• Effective 05/01/2024 - 06/30/2024
• Effective 04/01/2024 - 04/30/2024 (*Magellan Behavioral Health Service as Administrator ceases)
• Effective 01/01/2024 - 03/31/2024
• Effective 10/01/2023 - 12/31/2023
• Effective 07/01/2023 - 09/30/2023
• Effective 04/01/2023 - 06/30/2023
• Effective 01/01/2023 - 03/31/2023
  
• Effective 10/01/2022 - 12/31/2022
• Effective 07/01/2022 - 09/30/2022 Posted 04/21/2022/Updated 05/17/2022
• Effective 04/01/2022 - 06/30/2022
• Effective 01/01/2022 - 03/31/2022

Prior Authorization List Change Summary

• Effective 07/01/2024
• Effective 05/01/2024 - 06/30/2024
  
• Effective 04/01/2024 - 04/30/2024 (*Magellan Behavioral Health Service as Administrator ceases)
• Effective 01/01/2024 - 03/31/2024
• Effective 10/01/2023 - 12/31/2023
• Effective 07/01/2023 - 09/30/2023
• Effective 04/01/2023 - 06/30/2023
• Effective 01/01/2023 - 03/31/2023
• Effective 10/01/2022 - 12/31/2022
• Effective 07/01/2022 - 09/30/2022 Posted 04/21/2022/Updated 05/17/2022
• Effective 04/01/2022 - 06/30/2022
• Effective 01/01/2022 - 03/31/2022

Prior Authorization Annual Reports

• 2023 Prior Authorization Annual Review Report
• 2023 Prior Authorization Annual Change Log

Utilization Management Archive

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.