For Service codes for which Cook Children's Health Plan (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 Texas Medicaid Provider Procedures Manual and the Medicaid Fee Schedule.
How to Submit a Prior Authorization
For medical authorization, Cook Children’s Health Plan accepts prior authorization requests via the following methods:
Behavioral Health Authorizations
Determining Medical Necessity
Cook Children’s Health Plan uses the following criteria resources for determining Medical Necessity:
* Proprietary and not available in paper copy. Cook Children’s Health Plan will assist Member and Providers in reviewing applicable criteria.
Authorization is always required for the following:
- Out of network authorization requests (except STAR Family Planning & Texas Health Steps medical checkups
- Inpatient admissions (not related to routine delivery length of stays; routine deliveries do not require prior authorization)
- Temporary codes for emerging technology, services, procedures
- Dental Anesthesia for STAR and STAR Kids Members under age 7
- Home Health Nursing Services
- Neuropsychological Testing
- Chiropractic Services exceeding 12 visits per year
- Physical, Occupational, and Speech Therapy Services
- Clinician Administered Drugs*
- Non-Emergency Transport
- Outpatient/Planned Surgical Procedures*
- Radiation Therapy
- Transplant and Related Services
- Bariatric treatment
- Durable Medical Equipment*
- Sonograms >3 per pregnancy
- Medications exceeding $10,000.00 that are not subject to Prior Authorization requirements by Navitus
- All T-Codes
- Request for services exceeding monthly allowable per the Texas Medicaid Provider Procedures Manual
*Only for those codes indicated on the Prior Authorization Lookup
Authorization is always required for the following:
Types of Authorization Requests
When you submit an authorization it is important that it is correctly labeled. Incorrect submissions may delay the response time. Below is an explanation of each type of request.
- 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 one hundred twenty (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 seventy two (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 twenty four (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 twenty four (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 twenty four (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.
CCHP will process prior authorization requests necessary to facilitate safe hospital discharge within seventy two (72) hours of the request being received. When submitting the authorization request, please indicate URGENT as the severity level. This may include, but is not limited to: Private Duty Nursing, Skilled Nursing Visits, Outpatient Rehabilitation (PT, ST, OT), and Durable Medical Equipment.
- 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
*Please note, emergent and post-stabilization services do not require prior authorization.
Providers must submit complete prior authorization requests in order for authorization to be processed as outlined.
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