Prior Authorization
For Service codes for which Cook Children's Health Plan does not require prior authorization, it remains the Provider's 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. All out of network services require prior authorization (except STAR and STAR Kids family planning, Texas Health Step services performed by those with valid Texas Health Steps Provider identifier, emergency care and physicians services for uncomplicated deliveries, and services provided by an Indian Health Care Provider enrolled as a FQHC).
How to Submit a Prior Authorization
Pharmacy Authorizations - Navitus Health Solutions
Vision Authorizations - National Vision Administrators
Behavioral Health Authorizations - Cook Children's Health Plan
For behavioral health authorization, Cook Children's Health Plan accepts prior authorization requests via the Secure Provider Portal.
Providers pending access to the Secure Provider Portal may submit requests via the following methods:
- Fax: 1-682-303-0005 or 1-844-843-0005 STAR KIDS
- Fax: 1-682-885-8402 STAR/CHIP
Provider inquiries may be sent to CCHPPriorAuthorizations@cookchildrens.org
Please reserve this for inquiries only. We request that this is not utilized for routine prior authorization requests.
Medical Authorizations – Cook Children’s Health Plan
For medical authorization, Cook Children's Health Plan accepts prior authorization requests via the Secure Provider Portal.
Providers pending access to the Secure Provider Portal may submit requests via the following methods:
- Fax: 1-682-303-0005 or 1-844-843-0005 STAR KIDS
- Fax: 1-682-885-8402 STAR/CHIP
Provider inquiries may be sent to CCHPPriorAuthorizations@cookchildrens.org
Please reserve this for inquiries only. We request that this is not utilized for routine prior authorization requests.
When submitting Prior Authorization requests using the Secure Provider Portal, we request revenue codes not be added unless required per TMPPM guidelines.
Determining Medical Necessity
Cook Children's Health Plan uses the following criteria resources for determining Medical Necessity:
- Texas Medicaid Provider Procedures Manual
- Including the Behavioral Health and Case Management Services Handbook
- InterQual™ Criteria Sets – Adult and Pediatric (Level of Care Acute Criteria, Rehabilitation, Home Health and Durable Medical Equipment)
- InterQual™ Behavioral Health Criteria Sets for Adult and Geriatric Psychiatry, Child and Adolescent Psychiatry, Substance Use Disorders, and Behavioral Health Services (outpatient services including psychotherapy, neuropsychological testing, psychological testing’s, Transcranial Magnetic Stimulation (TMS), Electroconvulsive Therapy (ECT)
- For Members receiving behavioral health services from the Local Mental Health Authority, Cook Children’s Health Plan will utilize the same UM guidelines as those prescribed for use by Local Mental Health Authorities by MHMR
- Cook Children's Health Plan Therapy Program Guidelines
- Autism Benefit Services
- Cook Children's Health Plan Clinical Information and Documents to Support Medical Necessity
- Hayes Technology, Inc*
- Up-To-Date*
*These criteria are available to Members, physician's and other professional Providers upon request.
For practitioners who do not have internet or fax access, a copy of the criteria is available by mail. Ask to speak with Utilization Management at one of the following numbers to initiate a request:
- STAR Kids Members: 1-800-843-0004
- CHIP and STAR Members: 1-800-964-2247
- Providers: 1-888-243-3312
To clarify or obtain assistance with prior authorization requirements you may contact Cook Children's Health Plan at 1-888-243-3312, Monday through Friday from 8:00 a.m. to 5:00 p.m., (excluding holidays).
To clarify or obtain assistance with pharmacy prior authorization requirements you may contact Navitus Health Solutions at 1-866-333-2757, 24 hours a day, 7 days a week, (Closed Thanksgiving and Christmas Day).
If you have questions or need help with prior authorization, please call Cook Children's Health Plan. We have staff available to take your call Monday through Friday from 8:00 a.m. to 5:00 p.m., except for state holidays.
STAR Kids Members:
1-844-843-0004
Local-682-885-0004
TTY/TDD-1-844-644-4137
Local-682-885-2138
CHIP/STAR Members:
1-800-964-2247
Local-682-885-2247
TTY/TDD-1-844-644-4137
Local-682-885-2138
Types of authorization requests
The Utilization Management department processes service requests in accordance with the clinical immediacy of the requested services.
- Prior Authorizations must be submitted via the Secure Provider Portal
Severity Type | Turnaround Time |
Routine | Within three (3) business days from the date Cook Children's Health Plan received the request |
Urgent | Within one (1) business day from the date Cook Children's Health Plan received the request |
Inpatient (Concurrent) | Within one (1) business day from the date Cook Children's Health Plan received the request |
Life Threatening | Within one (1) hour from receipt time by Cook Children's Health Plan |
Our pharmacy vendor, Navitus, will provide a prior authorization decision at the time of the call, when the caller is requesting a Medicaid prior authorization and has all the necessary information required to complete the prior authorization review.
For all others STAR/STAR Kids Medicaid prior authorization requests, Navitus will notify the prescriber's office of a prior authorization denial or approval no later than twenty-four (24) hours after receipt.
If Navitus cannot provide a response to the prior authorization request within twenty-four (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 situation, Navitus will allow the pharmacy to dispense a seventy-two (72) hour supply of the drug. This requirement applies to drugs which can be filled as a seventy-two (72) hour supply.
- Prior authorization requirements
- Prior authorization updates August 2024
- Prior authorization updates April 2024
- Prior authorization updates March 2024
- Prior authorization updates February 2024
- Prior authorization updates January 2024
- Prior authorization updates December 2023
- Prior authorization updates October 2023
- Prior authorization updates September 2023
- Prior authorization updates August 2023
- Prior authorization updates June 2023
- Prior authorization updates April 2023
- Prior authorization updates March 2023
- Prior authorization updates February 2023
- Prior authorization updates January 2023
- Prior authorization updates December 2022
- Prior authorization updates November 2022
- Prior authorization updates October 2022
- Prior authorization updates September 2022
- Member name
- Member number or Medicaid number
- Member date of birth
- Requesting Provider name
- Requesting Provider's National Provider Identifier (NPI)
- Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
Cook Children's Health Plan would like to ensure timely processing of all authorizations. Effective April 1, 2021, prior authorization requests with incomplete or missing information for Medicaid Members are processed as follows:
Cook Children's Health Plan must receive essential information in order to process a prior authorization request. Essential information includes all of the following:
- Member name
- Member ID number
- Member date of birth
- Requesting Provider's name
- Requesting Provider's National Provider Identifier (NPI)
- Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
If any essential information is not provided to Cook Children's Health Plan, the request cannot be processed. The request is returned to the requesting provider outlining the missing elements.
Additionally, the requesting provider should add any supporting clinical documentation he/she feels would be pertinent to prevent further delays in processing. Cook Children's Health Plan must receive sufficient clinical documentation to support medical necessity for a requested service.
Cook Children's Health Plan will process your request once any missing essential information and/or pertinent supporting clinical information is received.
If it is determined, upon review, that additional information is needed, a letter is sent to the Member, Requesting and Servicing Provider outlining the information needed. Cook Children's Health Plan must receive the requested information within 3 business days from the date of the letter. Additional information should be submitted to us via our Secure Provider Portal or faxed to 1-682-885-8402. Please reference the referral number provided on your letter. If the requested information is not received within the specified time frame, Cook Children's Health Plan is required by regulations to make a decision based solely on the information that we have.
If you wish to have a peer-to-peer discussion with our Medical Director, please contact Cook Children's Health Plan for scheduling by contacting 1-682-303-8248.
- Autism benefit services
- Physical, occupational and speech therapy guidelines
- Private duty nursing guidelines
Prior Authorization is always required for:
- Out of Network Services *
- Inpatient Admissions **
- Intensive Outpatient Psychiatry Services
- Partial Hospital Psychiatry Services
- Residential Treatment Services
- Home Health Nursing; Hospice
- Non-Emergency Ambulance Transport
- Plastic/Reconstruction/Cosmetic Procedures
- Radiation Therapy
- Transplants
- Emergency Dental Treatment for Dental Trauma
- Services not requiring Prior Authorization, but exceeding Texas Medicaid Provider Procedures Manual (TMPPM) limitations, billing requirements, and/or diagnosis
* All out of network services require prior authorization except STAR and STAR Kids family planning, Texas Health Steps services performed by those with valid Texas Health Steps Provider identifier, emergency care and physicians services for uncomplicated deliveries, and services provided by an Indian Health Care provider enrolled as a FQHC
** All inpatient admissions excluding routine vaginal deliveries <3 days and routine cesarean deliveries <5 days
- Comprehensive care program prior authorization request form
- Delivery notification form
- Durable medical equipment prior authorization request form
- High risk pregnancy notification form
- Non-emergency ambulance prior authorization form
- Palivizumab (Synagis) prior authorization request form
- Physical, occupational, or speech therapy prior authorization form
- Prior authorization request form
- Private duty nursing (PDN) authorization request packet
- STAR and STAR Kids authorized representative form
Providers must submit complete prior authorization requests in order for authorization to be processed as outlined.
Cook Children’s Health Plan endorses nationally recognized, evidence-based clinical practice guidelines that are based on needs and opportunities for improvement. Clinical practice guidelines are reviewed every two (2) years, or more frequently if national guidelines change within the two (2) year period. Cook Children’s Health Plan currently recommends the following clinical practice guidelines:
- Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder
- Endorsing Body: American Academy of Child and Adolescent Psychiatry
- Last Review Date: 10/12/2018
- Guidelines for the Diagnosis and Management of Asthma (EPR-3)
- Endorsing Body: National Heart, Lung, and Blood Institute
- Last Review Date: 10/12/2018
- Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics
- Endorsing Body: American Academy of Pediatrics
- Last Review Date: 10/12/2018
- Recommended Childhood and Adolescent Immunization Schedules: United States, 2019
- Endorsing Body: American Academy of Pediatrics Immunizations (aap.org)
- Last Review Date: 10/12/2018