Prior authorization requirements

Physical Health/Behavioral Health Determination Timelines

Utilization review timeliness standards:

• A written notice of final determination will be provided no later than the next business day following a prior authorization request determination.
• CHIP notifications:
  • For routine and urgent approvals, written/letter notification is required no later than the second business day after the date of the request.
  • For a member that is not hospitalized at the time of an adverse determination, notification will be provided within three business days in writing to the requesting provider and the member.
• Within one hour of receiving the request for post-stabilization or life-threatening conditions, except for emergency medical conditions and emergency behavioral health conditions where a prior authorization is not required.
• Providers can confirm that an authorization is on file by accessing the Availity Portal, https://www.availity.com, or by calling Provider Services at 800-454-3730. Staff are available Monday through Friday from 8 a.m. to 5 p.m. CT excluding state-observed holidays. You may leave a confidential voicemail after-hours and your call will be returned the next business day. If coverage of an admission has not been approved, the facility should contact Provider Services to resolve the issue.

Pharmacy prior authorization fax:

844-474-3341

Available 24/7

Pharmacy phone (at Amerigroup):

800-454-3730

Available 7 a.m. to 10 p.m. Central time

Medical injectable/infusible drugs prior authorization fax:

844-512-8995

Available 24/7

Prescriber offices calling our pharmacy prior authorization call center will receive an authorization approval or denial immediately. For all other prior authorization requests, Amerigroup will notify the prescriber’s office of an approval or denial no later than 24 hours after receipt.

If Amerigroup 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, the pharmacy has the ability to dispense a 72-hour supply of the drug. Directions for submitting a 72-hour supply are included in messaging sent to the pharmacy. If additional assistance is needed, pharmacies may contact the CarelonRx* Help Desk at 833-252-0329.

Providers must be prepared to supply relevant clinical information regarding the member’s need for a nonpreferred product or a medication requiring prior authorization. Only the prescribing physician or one of their staff representatives can request prior authorization. Decisions are based on medical necessity and are determined according to the Texas Vendor Drug Program (VDP)-established medical criteria. Most approved requests for prior authorization will be valid for one year, although some medications may require review more often.

* CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Amerigroup.

CHIP, STAR, STAR+PLUS:

800-600-4441 (TTY 711)

Available Monday through Friday from 7 a.m. to 6 p.m. Central time

STAR Kids:

844-756-4600 (TTY 711)

Available Monday through Friday from 8 a.m. to 6 p.m. Central time

CHIP, STAR, STAR+PLUS:

833-235-2022 (TTY 711)

STAR Kids:

833-370-7463 (TTY 711)

Inpatient:

1-844-430-6805

Outpatient:

1-844-442-8010

Services billed with the following revenue codes always require precertification:

Pharmacy

Check the Texas Vendor Drug Program formulary and Preferred Drug List at www.txvendordrug.com.

Services billed with the following revenue codes always require prior authorization:

Amerigroup uses Texas Vendor Drug Program (VDP) Prior Authorization criteria. The criteria is posted here.

A list of drugs to which each clinical policy applies is included in each individual policy.

VDP publishes a chart that shows which prior authorization policies each Managed Care Organization has opted into. The chart is posted here.