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 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.
Medicaid/CHIP Pharmacy Prior Authorization Submissions
Online pharmacy prior authorization: https://www.covermymeds.com
Pharmacy prior authorization fax:
Pharmacy phone (at Amerigroup):
Available 7 a.m. to 10 p.m. Central time
Medical injectable/infusible drugs prior authorization fax:
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.
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 VDP-established medical criteria. Most approved requests for prior authorization will be valid for one year, although some medications may require review more often.
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:
800-600-4441 (TTY 711)
Available Monday through Friday from 7 a.m. to 6 p.m. Central time
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)
833-370-7463 (TTY 711)
Submit requests through our Interactive Care Reviewer (ICR) tool via Availity.
You may also fax requests for services that require prior authorization to:
Services billed with the following revenue codes always require precertification:
|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|
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:
|0632||Pharmacy multiple sources|
STAR+PLUS Nursing Facility
The following always require prior authorization:
Elective services provided by or arranged at nonparticipating facilities.