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Care Management-Prior Authorization

Prior Authorization

Cook Children’s Health Plan Member’s must seek services from Cook Children’s Health Plan network providers. Providers may refer to any specialist or OB/GYN within the Cook Children’s Health Plan network. Providers must ensure that all necessary prior authorizations are obtained prior to providing services. Covered services listed by code on the most current version of the Cook Children’s Health Plan Services Requiring Prior Authorization list is available on our website or by fax upon request.

CCHP accepts prior authorization requests via the following methods:

  • Fax: 682-303-0005 or 844-843-0005 *STAR KIDS
  • Fax: 682-885-8402 *STAR/CHIP
  • Phone: 682-885-2245 Main or 888-243-3312
  • Provider Portal: via the Secure Provider Portal

Acute Authorization Request*

Acute is defined as an illness or trauma with a rapid onset and short duration. A medical condition is considered chronic when 120 days have passed from the start of therapy or the condition is no longer expected to resolve or may be slowly progressive over an indefinite period of time.

*Please note that request for acute therapy authorization may be submitted by the servicing provider and must contain paperwork required per the CCHP Therapy Guidelines.

Routine Authorization Request

Routine care means health care for covered preventive and medically necessary health care services that are non-emergent or non-urgent. A non-emergent condition is a condition that is neither acute nor severe and can be diagnosed and treated immediately, or that allows adequate time to schedule an office visit for a history, physical, or diagnostic studies prior to diagnosis and treatment. Routine authorization requests will be processed within 72 hours from CCHP receiving the request.

Urgent Authorization Request*

Urgent condition means a health condition including an urgent behavioral health situation that is not an emergency but is severe or painful enough to cause a prudent layperson, possessing the average knowledge of medicine, to believe that his or her condition requires medical treatment evaluation or treatment within 24 hours by the Member’s Primary Care Provider or Primary Care Provider designee to prevent serious deterioration of the Member’s condition or health.

Urgent behavioral health situation means a behavioral health condition that requires attention and assessment within 24 hours but which does not place the Member in immediate danger to himself or herself or others and the Member is able to cooperate with treatment.

Urgent requests will be processed within 24 hours.

*Please note that requests submitted that are not urgent in nature, but rather submitted as urgent based on the delay in provider submission will be processed as routine authorization requests.

Emergent Authorization Request

An emergency medical condition means a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

  • Placing the patient’s health in serious jeopardy
  • Serious impairment to bodily functions

Emergent requests will be processed within 1 hour.

Services not requiring Prior Authorization

For service codes for which CCHP does not require prior authorization, it remains the providers’ responsibility to verify that the code is a benefit of Texas Medicaid by utilizing the TMPPM and the Medicaid Fee Schedule.

Prior Authorization documents and tools.

If you have any questions please call Provider Services at 1-888-243-3312 Monday through Friday from 8 a.m. to 5 p.m. or Contact us here