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Prior authorization

Referrals are not required for any services including specialty consultation. But prior authorization (PA) is needed for some outpatient care, out-of-network providers and planned hospital admissions. This is review for medical necessity and appropriate use of health services. Members do not need PA for emergency care.

We review and revise the PA list periodically. Only services involving medical management are subject to our review and approval before reimbursement.  You can find a current list of the services that need PA on the Provider Portal. You can also find out if a service needs PA by using ProPAT, our online PA search tool. 

Tips for requesting PA

Tips for requesting PA

 A request for PA doesn’t guarantee payment. We can’t reimburse you for unauthorized services. Follow these tips to make PA easier:

  

  • Register for the Provider Portal if you haven’t already.

  • Verify member eligibility before providing services.

  • Complete the Texas standard prior authorization request form (PDF) for all medical requests. Also, view other prior authorization forms.

  • Attach supporting clinical info or documents that support medical necessity, like Title XIX form, test results or info about failed conservative treatment.

  • Allow at least three business days for a response. We handle urgent requests for medically non-urgent services within the timeframes for a routine request.

  • Respond to requests for more info in a timely manner. The turnaround time begins when we receive all info necessary to make a decision.

Learn more about utilization management

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How to request PA

 

Here are the ways you can request PA:

Online

Complete the Texas standard prior authorization request form (PDF). Then, upload it to the Provider Portal.

Visit the Provider Portal

By fax

Complete the Texas standard prior authorization request form (PDF). Then, fax the form to 1-866-835-9589.

After you request PA, we’ll:

 

  • Review the info you submit
  • Verify eligibility and benefits for the member
  • Let you know the decision

Approvals

We’ll let you know about approvals.

 

Timing of approvals

We must make a decision within 2 business days for Members with CHIP and within 3 business days for Members with Medicaid.

 

Adverse determinations for prior authorizations

Before you receive an adverse determination, we’ll offer you an opportunity for a peer-to-peer review. 

 

Timing of determination

 

After we get a request, we’ll let you know about an adverse determination (not approved) right away. Then you’ll get a written notice and information about appeal rights.

 

Standard decisions means the services are not urgent. If we deny (don’t approve) or limit what you asked for, we will let you know in 3 business days. In some cases, we may take up to 14 days.

 

Expedited (urgent) decisions means a delay could be dangerous for a Member’s health. If we deny an urgent decision, we will let you know in 72 hours. In some cases, we may take up to 14 days.

 

We make decisions following these timelines:

 

  • For standard decisions that deny or limit services, within 3 business days and no later than 14 calendar days.
  • For standard decisions with incomplete information, by the 10th business day of receiving a complete request and no later than 14 calendar days.
  • For standard decisions when an extension is requested by a Member or Provider, no later than 14 calendar days.
  • For all standard decisions, we will send the notice as soon as is needed for the Member’s condition, but no later than the date the extension expires (when we said we would make a decision).
  • For expedited decisions, no later than 72 hours unless the decision requires an extension.
  • For expedited decisions when a Member requests an extension or we believe the decision is very important for the Member, up to 14 calendar days.

We require all essential info when reviewing PA requests. If info to determine medical necessity is missing, illegible or incomplete, this is an incomplete PA request. We’ll let you and the member know, in writing, of missing info no later than three business days after the date we received the PA request.

 

We’ll contact you in writing to get the necessary info to resolve the incomplete PA request. Our written request for more info includes:

 

  • A statement that we reviewed the PA request and aren’t able to make a decision about the requested services without more info
  • A clear and specific list and description of missing, incomplete or incorrect info that you must submit for us to consider the request complete
  • An applicable timeline for you to submit the missing info
  • Info on how you can contact us

  • Member name
  • Member number or Medicaid number
  • Member date of birth
  • Your (requesting provider’s) name
  • Your (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 request

Start date for services

We use the date that we received the complete request form to determine the start date for services. Previous submission dates with missing or incomplete essential information are not considered when determining the start date of service.

 

Timeline for adverse benefit determinations

If we don’t receive the info we requested within three business days from the date we sent you the notice, the result will be an adverse benefit determination. We’ll refer the incomplete PA request to the medical director with all info we received in the initial PA request. The medical director should complete the determination within three business days of our referral. The total time to send the notice will not be more than described above in the section on Adverse Determination for Prior Authorizations.

Before issuing an adverse benefit determination, a medical director will offer a peer-to-peer review to discuss the:

 

  • Member’s plan of treatment
  • Clinical basis for the medical necessity determination

We allow one business day or a reasonable timeframe before issuing an adverse benefit determination.

 

We make a final determination within three business days after the date you provide any missing info.

 

If we don’t approve services based on medical necessity, we’ll send the appropriate notice of action to you and the member. The notice includes:

 

  • An explanation of the determination
  • The member’s rights for internal appeal
  • The member’s rights and processes for a state fair hearing with or without external independent review

 

Adverse determination letter templates

 

Aetna Better Health® of Texas - Medicaid (PDF)

 

Aetna Better Health of Texas - CHIP (PDF)

 

Aetna Medicaid member rights (PDF)

 

Remember, a request for PA isn’t a guarantee of payment. We can’t reimburse unauthorized services.

Authorization requests: Clinical Information and Documents (PDF)

 

PAs effective from September 1, 2019 to present

 

TX Prior Authorization STAR KIDS (PDF)

 

TX Prior Authorization STAR (PDF)

 

TX Prior Authorization CHIP (PDF)

 

TX Prior Authorization CHIP PERINATE (PDF)

The process for requesting services for a member in the hospital:

 

  1. Complete the Texas standard prior authorization request form (PDF).
  2.  Fax the completed form to 1-866-706-0529.
  3.  Include any clinical info that supports medical necessity, such as clinical notes, test results and daily treatment plan.

Timeline for concurrent review

 

  • We’ll complete decisions for concurrent review within one business day. If you receive a denial letter, you can contact us within one business day of receipt of the notification to set up a peer-to-peer review. This is for possible reconsideration. 
  • After two business days, the case will need to follow the appeal process in the denial letter.
  • We review requests for services or equipment necessary for the care of a member immediately after discharge in one business day.
  • You’ll want to respond to requests for more info in a timely manner. The turnaround time begins when we receive all the necessary info to make a determination.

Note: Post-stabilization or life-threatening conditions don’t require PA.

You can leave a message with questions for us anytime. We return calls from 8 AM to 5 PM CT. Just call the number for the plan and service area you need.

 

Phone numbers and service areas for members and providers

 

We can also provide callers with TDD/TTY and language help.

 

When initiating or returning calls about UM questions, we require staff to identify themselves by:

 

  • Name
  • Title
  • Organization name

And upon request, they share specific UM requirements and procedures verbally with:

 

  • Facility personnel
  • Attending physicians
  • Other ordering practitioners and providers

Fax requests

 

  • PA: 1-866-835-9589
  • Concurrent review: 1-866-706-0529

Annual review of PA criteria (PDF) was completed on September 2023.

 

Change Report (PDF)

 

Need more info?

Check out your provider manual (PDF). Or contact us based on the plan and service area. Visit our pharmacy PA page for info about PA for medications.

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