Prior authorization requirements
To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
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Physical health/behavioral health determination timelines
Utilization review timeliness standards:
| Program | Authorization type | Decision time frame |
| Medicaid | Routine/non-urgent | Three business days |
| CHIP | Routine/non-urgent | Two business days (approval) Three business days (adverse determination) |
| Medicaid and CHIP | Urgent/expedited | Three calendar days |
| Medicaid and CHIP | Concurrent | One business day |
| Medicaid and CHIP | Post-service | 30 calendar days |
- 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 , or by calling Provider Services at 1-833-731-2162. 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.
Medicaid/CHIP pharmacy prior authorization submissions
Online pharmacy prior authorization: CoverMyMeds
Pharmacy prior authorization fax:
Available 24/7
Pharmacy phone (at Wellpoint):
Available 7 a.m. to 10 p.m. CT
Medical injectable/infusible drugs prior authorization fax:
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, Wellpoint will notify the prescriber’s office of an approval or denial no later than 24 hours after receipt.
If Wellpoint 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 Wellpoint.
Member assistance with prior authorizations
Members who have questions regarding prior authorizations may contact Member Services. Members can also live chat with a representative or send a secure message once a member logs into their account.
CHIP, STAR, STAR+PLUS:
1-833-731-2160 (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
If you have any questions regarding pharmacy prior authorizations, contact Pharmacy Member Services, available 24/7:
CHIP, STAR, STAR+PLUS:
833-235-2022 (TTY 711)
STAR Kids:
833-370-7463 (TTY 711)
Behavioral health
Submit requests through our Interactive Care Reviewer (ICR) tool via Availity .
You may also fax requests for services that require prior authorization to:
Inpatient:
Outpatient:
Services billed with the following revenue codes always require prior authorization:
| 0240–0249 | all-inclusive ancillary psychiatric |
| 0901, 0905–0907, 0913 and 0917 | behavioral health treatment services |
| 0944–0945 | other therapeutic services |
| 0961 | psychiatric professional fees |
Pharmacy
Services billed with the following revenue codes always require prior authorization:
| 0632 | Pharmacy multiple sources |
Pharmacy resources:
Texas Vendor Drug Program formulary and preferred drug list
Texas Vendor Drug Program (VDP) prior authorization criteria
Texas Vendor Program prior authorization policies chart by MCO
Note: A list of drugs to which each clinical policy applies is included in each individual policy.
Long-Term Services and Supports
All long-term services and supports require prior authorization before services are rendered. Please use the fax numbers below to submit your requests.
STAR Kids
Fax: 1-844-756-4604
STAR+PLUS
Austin
Fax: 1-877-744-2334
STAR+PLUS
Lubbock
Fax: 1-888-822-5761
STAR+PLUS
STAR+PLUS Nursing Facility
Fax: 1-844-206-3445
STAR+PLUS
El Paso
Fax: 1-888-822-5790
STAR+PLUS
San Antonio
Fax: 1-877-820-9014
STAR+PLUS
Houston/Beaumont
Fax: 1-888-820-6828
STAR+PLUS
Tarrant/RSA
Fax: 1-888-562-5160
Provider tools & resources
- Log in to Availity
- Launch Provider Learning Hub
- Learn about Availity
- Precertification Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Referrals
- Forms
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)
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