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Prior authorization lookup

Authorization always required for: Out of network services (except STAR family planning & THSteps); Inpatient admissions (not related to STAR member delivery usual LOS); Home Health Nursing; Hospice; Non-Emergency Transport; Plastic/Reconstruction/Cosmetic Procedures; Radiation Therapy; Transplants; Emergency Dental Treatment for Dental Trauma


Cook Children's Health Plan
Prior Authorization List
Effective April 1, 2015
CHIP and Medicaid
  • ALL OUT-OF-NETWORK SERVICES
  • BARIATRIC SURGERY
  • CHIROPRACTIC TREATMENT
    **Initial evaluation visit does not require precertification
  • DURABLE MEDICAL EQUIPMENT (RENTAL OR PURCHASE)
    ****See attached list of DME requiring precertification
  • INPATIENT ADMISSIONS (including acute, skilled nursing and rehabilitation facilities)
    **CCHP Care Management must be notified of emergency admissions within one business day of admission.
  • EMERGENCY TREATMENT FOR DENTAL TRAUMA
  • HOME HEALTH SERVICES (all services except PT/OT/ST)
    **Medications given in the home require approval from the Vendor Drug Program.
  • HOSPICE
  • IMAGING
    Positron Emission Tomography (PET),
    Single Photon Emission Computed Tomography (SPECT)
  • INFUSIONS/INJECTABLES (given in the office or clinic)
    **Medications given in the home require approval from the Vendor Drug Program.
    Includes: Botox, Synagis, Lupron, intravenous immunoglobulins (IVIG), Remicaid, biotech drugs.
    Does Not Include: Immunizations, antibiotics, chemotherapy, allergy serum.
  • MATERNITY – notification high risk OB only
  • NEUROPSYCHOLOGICAL TESTING (related to organic disease)
  • NON-EMERGENCY AMBULANCE TRANSPORT
  • ORTHOGNATHIC SURGERY
  • OUTPATIENT/AMBULATORY SURGERY
    **See attached list of procedures requiring precertification.
  • PLASTIC, RECONSTRUCTIVE OR COSMETIC PROCEDURES
  • RADIATION THERAPY
  • TEMPORARY CPT CODES FOR EMERGING TECHNOLOGY, SERVICES, AND PROCEDURES (CATEGORY III CPT CODES)
  • TRANSPLANTS

Use the search below for specific services requiring Prior Authorization

Prior Authorization Lookup
Service Code:   Date of Service:




Please note: "Authorization not required" response is not a guarantee of payment. Payment is subject to the member's eligibility and benefits on the date of service. Please verify benefit limitations per the TMHP Providers Procedures Manual. Call Care Management if you have any questions.