Información sobre la autorización previa

Prior Authorization Information

Click here to return to the Member site.

Haga clic aquí para volver al sitio de miembros. 

Para la versión en español, haga clic aquí.

What is a prior authorization?

(Medicaid) Prior authorization verifies whether medical treatment that is not an emergency is medically necessary.  It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Community Health Choice will also verify if the Member has benefits.

Prior authorization is sometimes called pre-certification or pre-notification.

Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Community must still process a Provider’s claim to determine if payment will be made. The claim is processed according to:

  • Eligibility;
  • Contract limitations;
  • Benefit coverage guidelines;
  • Applicable State or Federal requirements;
  • National Correct Coding Initiative (NCCI) edits;
  • Texas Medicaid Provider Procedures Manual (TMPPM); and
  • Other program requirements, as applicable.

Click here to review the Annual PA Statistics for 2025.

Click here to review the Annual PA Statistics for 2024. 

Annual PA Metrics 2025

Please contact us if you have questions or need assistance with prior authorizations.

Medicaid Hours
Monday – Friday, 8:00 a.m. – 5:00 p.m.
Saturday/Sunday/Holidays, 9:00 a.m. – 12:00 p.m.

CHIP Hours
Monday – Friday, 6:00 a.m. – 6:00 p.m.
Saturday/Sunday/Holidays, 9:00 a.m. – 12:00 p.m.

Phone
713.295.2295 or toll free 1.888.760.2600

Pharmacy Prior Authorization Assistance
1.877.908.6023

Website
https://Provider.communityhealthchoice.org/resources/

Email

Please contact us if you have questions or need assistance with medical/pharmacy prior authorizations.

Local: 713.295.2294
Toll-Free: 1.888.760.2600
TDD Number for Hearing Impaired 7-1-1

Monday through Friday (excluding State-approved holidays)

8:00 a.m. to 6:00 p.m.

Click here to view the August 10, 2026 catalog.

Click here to view the July 1, 2026 catalog.

Click here to view the May 1, 2026 catalog

Click here to view the May 1, 2026 catalog

Click here to view the March 1, 2026 catalog

Click here to view the January 1, 2026 catalog

Click here to view the December 1, 2025 catalog

Click here to view the November 1, 2025 catalog

Click here to view the October 1, 2025 catalog

Click here to view the August 1, 2025 catalog

Click here to view the June 1, 2025 catalog

Click here to view the June 1, 2025 catalog

Click here to view the May 1, 2025 catalog

Click here to view the April 1, 2025 catalog

Click here to view the March 1, 2025 catalog

Click here to view the February 2025 catalog

Click here to view the January 2025 catalog

Click here to view the November 2024 catalog

Click here to view the October 2024 catalog

Click here to view the June 2024 catalog

Click here to view the April 2024 catalog

Click here to view the 2024 catalog.

Click here to view the 2023 catalog.

Click here to view the 2022 catalog.

Click here to review the Prior Authorization Annual Review Report 2025. 

Click here to review the Prior Authorization Annual Review Report 2024. 

Click here to review the Prior Authorization Annual Review Report 2023. 

Click here to review the Prior Authorization Annual Review Report 2019. 

Click here to review the Prior Authorization Change Log.

Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.

Prior Authorization Submission

Please note: Provider may submit a prior authorization or service authorization request for services at least 60 days prior to the expiration of current authorization period. Community will review the request and issue a determination prior to the expiration of the existing authorization.

  • For Transplant Prior Authorization Requests and Clinical Submission, Community accepts prior authorization requests via the following methods:
  • For Behavioral Health Authorizations, Community accepts prior authorization requests via the following methods:
    • Community Health Choice secure provider portal
    • Fax: 713.576.0932 (Inpatient)
    • Fax: 713.576.0931 (Outpatient)

Providers must submit the Prior Authorization Request Form, which you can view and download here.  The form must include the following information to initiate the prior authorization review process:

  • Member’s name
  • Member date of birth
  • Member number or Medicaid number
  • 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

Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted.

Supporting Clinical Documentation

Supporting documentation necessary to obtain prior authorization for a specified service includes a completed TSPA form, current clinical records that support the requested service, and any other documentation as per the TMPPM, (ex. Sterilization Consent Form, The Criteria for Dental Therapy under General Anesthesia Form, etc.)

Click here for the Clinical Practice Guidelines

Click here for a list of requirements for Transplants.

Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:

  • Peer-reviewed, published medical journals.
  • Evidence-based consensus statements
  • Practice guidelines/standards from professionally recognized health care organizations
  • Evidence-based research reviews of a particular topic/technology

Our MRGs are used when the Texas Medicaid Provider Procedures Manual (TMPPM) does not have any clinical criteria for certain services. Our review guidelines are applied in the following order:

  • State/Federal guidelines and Contract Requirements
  • MRGs
  • TMPPM
  • InterQual
– MRG: ABA Services
 
Although some MRGs may assist with coverage decisions, recommendations contained in the MRGs are not a guarantee of coverage. Community’s MRGs are available upon request.

Lack of Information

When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:

  • Community will notify the Member by letter that an authorization request was received, but cannot be acted upon until Community receives the missing documentation/information from the requesting Provider. The letter will include the following information:
    • A statement that Community has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
    • A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
    • An applicable timeline for the provider to submit the missing information.
    • Information on the manner through which a provider may contact Community.
  • Community will contact Provider via fax or phone and request documentation for completion of the medical necessity review within three business days of Community’s receipt of request.
  • If Community does not receive the documentation/information by the end of the third business day of Community’s request to the requesting Provider, the request will be submitted to the Medical Director no later than the seventh business day after receipt of request.
  • Community will make a decision no later than the tenth business day after the request received date.

Start of Care (SOC) exceptions will be approved when a Provider is able to submit additional information sufficient to classify a request as complete and the MCO has determined that requested services meet medical necessity from the SOC date.

ServiceInitial AuthorizationRe-certification of Authorization
Therapy (PT/OT/ST)Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated. Requests received after the five-business-day period will be denied for dates of service that occurred before the date that the PA request was received.Requests for recertification services received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. Should not be received >30 days before expiration of previous authorization.
Private Duty NursingInitial requests must be submitted within three business days of the SOC date.A recertification request must be submitted at least 7 calendar days before, but no more than 30 days before, a current authorization period will expire.
DMEPrior authorization must be obtained for some supplies and most DME within three business days of the DOS.Prior authorization must be obtained for some supplies and most DME within three business days of the DOS.

Community issues a determination within the following timeframes according to state regulatory requirements.

Prospective Review

  • Emergency Medical or Emergency Behavioral Conditions do not require prior authorization
  • Urgent – As soon as possible based on the clinical situation, but no later than one business day from receipt of a request for a Utilization Management (UM) determination
  • Routine – Within three business days from the receipt of a request for a UM determination
  • Inpatient – Within one business day from the receipt of a request for a UM determination
  • Post-hospitalization or life-threatening conditions – within one hour from the receipt of a request

Concurrent Review

Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than one business day.

Retrospective Review

Based on the Retrospective Review Policy for authorizations, if certain conditions are met Community will issue a determination, Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.

Pharmacy

  • Urgent – if prescribing Provider calls Community, Community will provide prior authorization approval or denial immediately.
  • Routine – Community will notify the prescribing Provider of prior authorization denial or approval no later than 24 hours after receipt.
  • If Community cannot provide response to a prior authorization request within 24 hours after receipt or the prescriber is unavailable to make request (after-hours) and dispensing pharmacist determines it is an emergency, Community will allow the pharmacy to dispense a 72-hour supply of the drug.

Community will deny a claim if the Provider does not obtain an authorization prior to providing services to a Member.  In no event will a Member be financially responsible for payments for such services, except for those Member expenses that are required under the Member’s specific benefit plan/program.

Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting.  Discharge planning may include, but is not limited to the following:

  • Home Health Services
    • Skilled Nurse Visits
    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
  • Outpatient Services – Physical Therapy, Occupational Therapy, Speech Therapy
  • Durable Medical Equipment (including supplies)
  • Any other urgent discharge needs for the Member’s transition back into the home setting

Please submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility. 

If a Member is discharged during non-business hours and/or the weekend, Providers should submit discharge planning requests the following business day.  All discharge authorizations are reviewed for evaluation and initial treatment.

For a continuation of treatment and services after discharge authorization, new physician orders from the Member’s PCP or Specialist are required. These requests must be submitted to the appropriate fax number for prior authorization requests. 

  • Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
  • Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
  • For Members transitioning from an Acute hospital to LTAC or SNF:
    • Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
  • For Members transitioning  from an Acute hospital, LTAC or SNF to Home (place of residence):
    • Fax request (PA form and discharge orders with clinical information  to: 713.848.6940
  • Fax Behavioral Health authorization requests to: 713.576.0932

All discharge planning authorization requests follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.

If an authorization request does not meet medical necessity, a Medical Director will review the request.

Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.

Peer to Peer Timeframes:

  • No less than one working day prior to issuing a prospective (pre-service/outpatient) utilization review adverse determination.
  • No less than five working days prior to issuing a retrospective review adverse determination.
  • Prior to issuing a concurrent (inpatient) or post stabilization review adverse determination or post-stabilization review adverse determination.

To request a Peer-to-Peer discussion, please call 713.295.2319.

Click here to return to the Member site.

Haga clic aquí para volver al sitio de miembros. 

Para la versión en español, haga clic aquí.

What is a prior authorization?

STAR+PLUS Prior authorization verifies whether medical treatment that is not an emergency is medically necessary.  It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Community Health Choice will also verify if the Member has benefits.

Prior authorization is sometimes called pre-certification or pre-notification.

Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Community must still process a Provider’s claim to determine if payment will be made. The claim is processed according to:

  • Eligibility;
  • Contract limitations;
  • Benefit coverage guidelines;
  • Applicable State or Federal requirements;
  • National Correct Coding Initiative (NCCI) edits;
  • Texas Medicaid Provider Procedures Manual (TMPPM); and
  • Other program requirements, as applicable.

Click here to review the Annual PA Statistics for 2025.

Click here to review the Annual PA Statistics for 2024. 

Annual PA Metrics 2025

Please contact us if you have questions or need assistance with prior authorizations.

STAR+PLUS Hours
8:00 a.m. – 5:00 p.m., Monday – Friday, excluding state-approved holidays.

Phone
Local: 713.295.2300  Toll Free: 1.888.495.2850

Pharmacy Prior Authorization Assistance
1.877.908.6023

Website
https://Provider.communityhealthchoice.org/resources/

Email

Please contact us if you have questions or need assistance with medical/pharmacy prior authorizations.

Local: 713.295.2300  Toll Free: 1.888.435.2850

Number for Hearing Impaired TTY 7-1-1

8:00 a.m. – 5:00 p.m., Monday – Friday, excluding state-approved holidays.

Click here to view the August 10, 2026 catalog

Click here to view the July 1, 2026 catalog

Click here to view the May 1, 2026 catalog

Click here to view the January 1, 2026 catalog

Click here to view the December 1, 2025 catalog

Click here to view the November 1, 2025 catalog

Click here to view the October 1, 2025 catalog

Click here to view the August 1, 2025 catalog

Click here to view the June 1, 2025 catalog

Click here to view the May 1, 2025 catalog

Click here to view the April 1, 2025 catalog

Click here to view the March 1, 2025 catalog

Click here to view the February 2025 catalog

Click here to view the January 2025 catalog

Click here to view the November 2024 catalog

Click here to view the September 2024 catalog

Click here to review the Prior Authorization Annual Review Report 2025. 

Click here to review the Prior Authorization Annual Review Report 2024. 

Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.

Prior Authorization Submission

Please note: Provider may submit a prior authorization or service authorization request for services at least 60 days prior to the expiration of current authorization period. Community will review the request and issue a determination prior to the expiration of the existing authorization.

  • For Transplant Prior Authorization Requests and Clinical Submission, Community accepts prior authorization requests via the following methods:
  • For Behavioral Health Authorizations, Community accepts prior authorization requests via the following methods:
    • Community Health Choice secure provider portal
    • Fax: 713.576.0852 (Inpatient)
    • Fax: 713.576.0852 (Outpatient)

Providers must submit the Prior Authorization Request Form, which you can view and download here.  The form must include the following information to initiate the prior authorization review process:

  • Member’s name
  • Member date of birth
  • Member number or Medicaid number
  • 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

Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted.

Supporting Clinical Documentation

Supporting documentation necessary to obtain prior authorization for a specified service includes a completed TSPA form, current clinical records that support the requested service, and any other documentation as per the TMPPM, (ex. Sterilization Consent Form, The Criteria for Dental Therapy under General Anesthesia Form, etc.)

Click here for the Clinical Practice Guidelines

Click here for a list of requirements for Transplants.

Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:

  • Peer-reviewed, published medical journals.
  • Evidence-based consensus statements
  • Practice guidelines/standards from professionally recognized health care organizations
  • Evidence-based research reviews of a particular topic/technology

Our MRGs are used when the Texas Medicaid Provider Procedures Manual (TMPPM) does not have any clinical criteria for certain services. Our review guidelines are applied in the following order:

  • State/Federal guidelines and Contract Requirements
  • MRGs
  • TMPPM
  • InterQual
 
Although some MRGs may assist with coverage decisions, recommendations contained in the MRGs are not a guarantee of coverage. Community’s MRGs are available upon request.

Lack of Information

When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:

  • Community will notify the Member by letter that an authorization request was received, but cannot be acted upon until Community receives the missing documentation/information from the requesting Provider. The letter will include the following information:
    • A statement that Community has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
    • A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
    • An applicable timeline for the provider to submit the missing information.
    • Information on the manner through which a provider may contact Community.
  • Community will contact Provider via fax or phone and request documentation for completion of the medical necessity review within three business days of Community’s receipt of request.
  • If Community does not receive the documentation/information by the end of the third business day of Community’s request to the requesting Provider, the request will be submitted to the Medical Director no later than the seventh business day after receipt of request.
  • Community will make a decision no later than the tenth business day after the request received date.

Start of Care (SOC) exceptions will be approved when a Provider is able to submit additional information sufficient to classify a request as complete and the MCO has determined that requested services meet medical necessity from the SOC date.

ServiceInitial AuthorizationRe-certification of Authorization
Therapy (PT/OT/ST)Initial prior authorization (PA) requests must be received no later than five business days from the date therapy treatments are initiated. Requests received after the five-business-day period will be denied for dates of service that occurred before the date that the PA request was received.Requests for recertification services received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. Should not be received >30 days before expiration of previous authorization.
Private Duty NursingInitial requests must be submitted within three business days of the SOC date.A recertification request must be submitted at least 7 calendar days before, but no more than 30 days before, a current authorization period will expire.
DMEPrior authorization must be obtained for some supplies and most DME within three business days of the DOS.Prior authorization must be obtained for some supplies and most DME within three business days of the DOS.

Community issues a determination within the following timeframes according to state regulatory requirements.

Prospective Review

  • Emergency Medical or Emergency Behavioral Conditions do not require prior authorization
  • Urgent – As soon as possible based on the clinical situation, but no later than one business day from receipt of a request for a Utilization Management (UM) determination
  • Routine – Within three business days from the receipt of a request for a UM determination
  • Inpatient – Within one business day from the receipt of a request for a UM determination
  • Post-hospitalization or life-threatening conditions – within one hour from the receipt of a request

Concurrent Review

Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.

Retrospective Review

Based on the Retrospective Review Policy for authorizations, if certain conditions are met Community will issue a determination, Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.

Pharmacy

  • Urgent – if prescribing Provider calls Community, Community will provide prior authorization approval or denial immediately.
  • Routine – Community will notify the prescribing Provider of prior authorization denial or approval no later than 24 hours after receipt.
  • If Community cannot provide response to a prior authorization request within 24 hours after receipt or the prescriber is unavailable to make request (after-hours) and dispensing pharmacist determines it is an emergency, Community will allow the pharmacy to dispense a 72-hour supply of the drug.

Community will deny a claim if the Provider does not obtain an authorization prior to providing services to a Member.  In no event will a Member be financially responsible for payments for such services, except for those Member expenses that are required under the Member’s specific benefit plan/program.

Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting.  Discharge planning may include, but is not limited to the following:

  • Home Health Services
    • Skilled Nurse Visits
    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
  • Outpatient Services – Physical Therapy, Occupational Therapy, Speech Therapy
  • Durable Medical Equipment (including supplies)
  • Any other urgent discharge needs for the Member’s transition back into the home setting

Please submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility. 

If a Member is discharged during non-business hours and/or the weekend, Providers should submit discharge planning requests the following business day.  All discharge authorizations are reviewed for evaluation and initial treatment.

For a continuation of treatment and services after discharge authorization, new physician orders from the Member’s PCP or Specialist are required. These requests must be submitted to the appropriate fax number for prior authorization requests. 

  • Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
  • Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
  • For Members transitioning from an Acute hospital to LTAC or SNF:
    • Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
  • For Members transitioning  from an Acute hospital, LTAC or SNF to Home (place of residence):
    • Fax request (PA form and discharge orders with clinical information  to: 713.848.6940
  • Fax Behavioral Health authorization requests to: 713.576.0932

All discharge planning authorization requests follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.

If an authorization request does not meet medical necessity, a Medical Director will review the request.

Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.

Peer to Peer Timeframes:

  • No less than one working day prior to issuing a prospective (pre-service/outpatient) utilization review adverse determination.
  • No less than five working days prior to issuing a retrospective review adverse determination.
  • Prior to issuing a concurrent (inpatient) or post stabilization review adverse determination or post-stabilization review adverse determination.

To request a Peer-to-Peer discussion, please call 713.295.2319.

Click here to return to the Member site.

Haga clic aquí para volver al sitio de miembros. 

Para la versión en español, haga clic aquí.

¿Qué es una autorización previa?

(Medicaid) La autorización previa verifica si un tratamiento médico que no sea de emergencia es médicamente necesario. También determina si el tratamiento se ajusta al diagnóstico y si los servicios solicitados se prestarán en un entorno adecuado. Durante el proceso de autorización previa, Community Health Choice también verificará si el miembro cuenta con beneficios.

En ocasiones, la autorización previa se denomina precertificación o prenotificación

La autorización previa NO garantiza el pago. Incluso si un proveedor obtuvo la autorización previa requerida, Community aún debe procesar la reclamación del proveedor para determinar si se realizará el pago. La reclamación se procesa de acuerdo con lo siguiente:

  • Elegibilidad.
  • Limitaciones del contrato.
  • Pautas de cobertura de beneficios.
  • Requisitos estatales o federales aplicables.
  • Ediciones de la Iniciativa Nacional de Codificación Correcta (NCCI).
  • Manual de Procedimientos para Proveedores de Medicaid de Texas (TMPPM).
  • Otros requisitos del programa, según corresponda.

Haga clic aquí para consultar las estadísticas anuales de Autorizaciones Previas (PA) correspondientes al año 2025.

Haga clic aquí para consultar las estadísticas anuales de Autorizaciones Previas (PA) correspondientes al año 2024. 

Estadísticas anuales de PA

Si tiene alguna duda o necesita ayuda con las autorizaciones previas, no dude en comunicarse con nosotros.

Horarios de Medicaid

Lunes a viernes, de 8:00 a. m. a 5:00 p. m.
Sábados, domingos y días festivos, de 9:00 a. m. a 12:00 p. m.

Horarios de CHIP

Lunes a viernes, de 6:00 a. m. a 6:00 p. m.
Sábados, domingos y días festivos, de 9:00 a. m. a 12:00 p. m.

Teléfono

713-295-2295 o línea gratuita 1-888-760-2600

Asistencia para la autorización previa de farmacia
1-877-908-6023

Sitio web

https://Provider.communityhealthchoice.org/resources/

Correo electrónico

[email protected]

Si tiene alguna pregunta o necesita ayuda con las autorizaciones previas médicas o farmacéuticas, comuníquese con nosotros.

Local: 713-295-2294
Línea gratuita: 1-888-760-2600
Número de TDD para personas con discapacidad auditiva: 7-1-1

De lunes a viernes (excepto días festivos autorizados por el Estado)
de 8:00 a.m. a 6:00 p.m.

Click here to view the August 10, 2026 catalog

Click here to view the July 1, 2026 catalog

Click here to view the May 1, 2026 catalog

Click here to view the May 1, 2026 catalog

Click here to view the March 1, 2026 catalog

Click here to view the January 1, 2026 catalog

Click here to view the December 1, 2025 catalog

Click here to view the November 1, 2025 catalog

Click here to view the October 1, 2025 catalog

Click here to view the August 1, 2025 catalog

Click here to view the June 1, 2025 catalog

Click here to view the May 1, 2025 catalog

Click here to view the April 1, 2025 catalog

Click here to view the March 1, 2025 catalog

Click here to view the February 2025 catalog

Click here to view the January 2025 catalog

Click here  to view the November 2024 catalog

Click here to view the October 2024 catalog

Click here to view the June 2024 catalog

Click here to view the April 2024 catalog

Click here to view the 2024 catalog.

Click here to view the 2023 catalog.

Click here to view the 2022 catalog.

Haga clic aquí para consultar el Informe de revisión anual de autorizaciones previas. 

Haga clic aquí para consultar el Registro de cambios de autorización previa.

Salvo en casos de emergencia, Community exige autorización previa para todos los servicios prestados por un proveedor no participante.

Para tener en cuenta: El proveedor puede presentar una solicitud de autorización previa o autorización de servicio al menos 60 días antes del vencimiento del período de autorización actual. Community revisará la solicitud y emitirá una resolución antes del vencimiento de la autorización vigente.

    • Para las solicitudes de autorización previa de trasplantes y las presentaciones clínicas, Community acepta solicitudes de autorización previa a través de los siguientes métodos:
    • En lo que respecta a las autorizaciones de salud conductual, Community acepta solicitudes de autorización previa a través de los siguientes métodos:

Los proveedores deben presentar el Formulario de solicitud de autorización previa, que puede consultar y descargar aquí.  Este formulario debe incluir la siguiente información para iniciar el proceso de revisión de la autorización previa:

  • Nombre del miembro
  • Fecha de nacimiento del miembro
  • Número de miembro o de Medicaid
  • Nombre del proveedor solicitante
  • Identificador Nacional de Proveedor (NPI) del proveedor solicitante
  • Nombre del proveedor que prestó el servicio
  • Identificador Nacional de Proveedor (NPI) del proveedor que prestó el servicio
  • Servicio solicitado:
    • Terminología de Procedimientos Actuales (CPT)
    • Sistema Común de Codificación de Procedimientos de Atención Médica (HCPCS)
    • Terminología Dental Actual (CDT)
  • Fechas de inicio y fin del servicio solicitado
  • Cantidad de unidades de servicio solicitadas según el CPT, HCPCS o CDT solicitado

Tenga en cuenta que no se procesarán las solicitudes de autorización previa que carezcan de información esencial y será necesario presentar una nueva solicitud.

Documentación clínica de respaldo

La documentación de respaldo necesaria para obtener la autorización previa de un servicio específico incluye un formulario de Autorización Previa Estándar de Texas (TSPA) completo, expedientes clínicos vigentes que respalden el servicio solicitado y cualquier otra documentación según lo establecido en el TMPPM (por ejemplo, el Formulario de consentimiento para esterilización, el Formulario de criterios para la terapia dental bajo anestesia general, etc.)

Haga clic aquí para consultar las guías de práctica clínica.

Haga clic aquí para ver la lista de requisitos para los trasplantes.

Community Health Choice (Community) cuenta con directrices clínicas internas denominadas Directrices de Revisión Médica (MRG), que constituyen uno de los conjuntos de directrices utilizados para determinar la necesidad médica y tomar decisiones de cobertura. Nuestras MRG son directrices basadas en la evidencia procedentes de las siguientes fuentes:

  • Revistas médicas publicadas y revisadas por pares
  • Declaraciones de consenso basadas en la evidencia
  • Pautas o estándares de práctica de organizaciones de atención médica reconocidas a nivel profesional
  • Revisiones de investigaciones basadas en la evidencia sobre un tema o tecnología en particular

Nuestras MRG se utilizan cuando el Manual de Procedimientos para Proveedores de Medicaid de Texas (TMPPM) no cuenta con criterios clínicos para ciertos servicios. Nuestras pautas de revisión se aplican en el siguiente orden:

  • Pautas estatales o federales y requisitos contractuales
  • MRG
  • TMPPM
  • InterQual

– MRG: medicamento administrado por un profesional clínico: lugar de atención

– MRG: determinación de la necesidad médica
– MRG: pruebas genéticas
– MRG: infliximab

– MRG: pautas de trasplantes y proceso de revisión 
– MRG: ecografías en el embarazo 

Aunque algunas MRG pueden servir para tomar decisiones sobre la cobertura, las recomendaciones que contienen no constituyen una garantía de cobertura. Las MRG de la comunidad están disponibles a solicitud.

Falta de información

Cuando Community reciba una solicitud de autorización previa y dicha solicitud no contenga la documentación clínica o la información completa:

  • Community notificará al Miembro por carta que se ha recibido una solicitud de autorización, pero que no se podrá procesar hasta que se reciba la documentación o información faltante del proveedor solicitante. La carta incluirá la siguiente información:
    • Una declaración de que Community ha revisado la solicitud de PA y no puede tomar una decisión sobre los servicios solicitados sin que se presente información adicional.
    • Una lista y descripción claras y específicas de la información o documentación que falta/está incompleta/es incorrecta, y que debe presentarse para que la solicitud se considere completa.
    • Un plazo aplicable para que el proveedor presente la información que falta.
    • Información sobre la forma en que un proveedor puede comunicarse con Community.
  • Community se comunicará con el proveedor por fax o por teléfono y le solicitará la documentación necesaria para completar la revisión de la necesidad médica dentro de los tres días hábiles siguientes a la recepción de la solicitud por parte de Community.
  • Si Community no recibe la documentación o información antes de que finalice el tercer día hábil a partir de la solicitud de Community al proveedor solicitante, la solicitud se remitirá al director médico antes del séptimo día hábil después de la recepción de la solicitud.
  • Community tomará una decisión antes del décimo día hábil después de la fecha de recepción de la solicitud.

Las excepciones al Inicio de la Atención (SOC) se aprobarán cuando un proveedor pueda presentar información adicional suficiente para clasificar una solicitud como completa y la Atención Médica Administrada (MCO) haya determinado que los servicios solicitados cumplen con la necesidad médica a partir de la fecha de SOC.

ServicioAutorización inicialRecertificación de la autorización
Terapia (fisioterapia [PT]/terapia ocupacional [OT]/terapia del habla [ST])Las solicitudes iniciales de autorización previa (PA) deben recibirse antes de los cinco días hábiles a partir de la fecha en que se inicien los tratamientos de terapia. Se rechazarán las solicitudes recibidas después del plazo de cinco días hábiles para las fechas de servicio que hayan ocurrido antes de la fecha en que se recibió la solicitud de PA.Se rechazarán las solicitudes de recertificación de servicios recibidas después del vencimiento de la autorización vigente para las fechas de servicio que hayan ocurrido antes de la fecha en que se recibió la solicitud. No deben recibirse más de 30 días antes del vencimiento de la autorización anterior.
Atención de enfermería particularLas solicitudes iniciales deben presentarse dentro de los tres días hábiles siguientes a la fecha de SOC.Las solicitudes de recertificación deben presentarse entre 7 y 30 días calendario antes del vencimiento del período de autorización vigente.
Equipos Médicos Duraderos (DME)Se debe obtener autorización previa para algunos suministros y la mayoría de los DME dentro de los tres días hábiles siguientes a la Fecha de Servicio (DOS).Se debe obtener autorización previa para algunos suministros y la mayoría de los DME dentro de los tres días hábiles siguientes a la Fecha de Servicio (DOS).

Los proveedores deben presentar el Formulario de solicitud de autorización previa, que puede consultar y descargar aquí.  El formulario incluirá la siguiente información:

  • Nombre del miembro
  • Fecha de nacimiento del miembro
  • Número de identificación del miembro a Medicaid/CHIP
  • Nombre del proveedor solicitante e Identificador Nacional de Proveedor (NPI)
  • Nombre del proveedor que presta el servicio y NPI
  • Servicio solicitado
  • Códigos de la Terminología de Procedimientos Actuales (CPT) solicitados
  • Cantidad de unidades solicitadas
  • Fechas de servicio
  • Firma con fecha del proveedor solicitante dentro de la red

Para evitar retrasos en la autorización o denegaciones administrativas, se recomienda a los proveedores que presenten documentación suficiente que valide la necesidad médica de los servicios solicitados. Esto puede incluir notas recientes de evolución, historia clínica y examen físico, resultados de radiología o laboratorio, notas o informes de consultas, planes de tratamiento que muestren el progreso hacia los objetivos (p. ej., solicitudes de terapia) o documentación similar del registro médico que ilustre la necesidad médica.

Community emite una determinación dentro de los siguientes plazos, de acuerdo con los requisitos regulatorios estatales.

Revisión prospectiva

  • Las condiciones médicas de emergencia o los trastornos conductuales de emergencia no requieren autorización previa
  • Urgente: lo antes posible según la situación clínica, pero en un plazo máximo de un día hábil a partir de la recepción de una solicitud de determinación de Gestión de Utilización (UM)
  • Rutina: dentro de los tres días hábiles  a partir de la recepción de una solicitud de determinación de UM
  • Hospitalización: dentro de un día hábil  a partir de la recepción de una solicitud de determinación de UM
  • Posthospitalización o afecciones de riesgo vital: dentro de una hora a partir de la recepción de la solicitud

Revisión simultánea

Community emite la determinación de reducción o terminación de un tratamiento previamente aprobado con suficiente anticipación para que el paciente pueda solicitar una revisión y recibir una decisión antes de que se produzca la reducción o terminación, pero en un plazo máximo de dos días hábiles.

Revisión retrospectiva

De acuerdo con la Política de revisión retrospectiva para autorizaciones, si se cumplen ciertas condiciones, Community emitirá una determinación dentro de los 30 días calendario a partir de la recepción de la solicitud de una resolución retrospectiva de UM sobre un servicio que el proveedor ya haya prestado y para el cual no haya presentado una reclamación. Envíe por fax las solicitudes de Revisión retrospectiva, junto con la documentación de respaldo, al 713-576-0937.

Farmacia

  • Urgente: si el proveedor que prescribe llama a Community, la entidad proporcionará la aprobación o denegación de la autorización previa de manera inmediata.
  • Rutina: Community notificará al proveedor que prescribe la denegación o aprobación de la autorización previa en un plazo máximo de 24 horas después de recibirla.
  • Si Community no puede ofrecer respuesta a una solicitud de autorización previa dentro de las 24 horas posteriores a su recepción o si el proveedor que prescribe no está disponible para realizar la solicitud (fuera del horario de atención) y el farmacéutico encargado de dispensar el medicamento determina que se trata de una emergencia, Community permitirá que la farmacia dispense un suministro del medicamento para 72 horas.

Community rechazará una reclamación si el proveedor no obtiene una autorización antes de prestar los servicios a un miembro.  En ningún caso el miembro tendrá responsabilidad financiera por los pagos de dichos servicios, salvo por aquellos gastos del miembro que le correspondan según su plan o programa de beneficios específico.

Community brinda servicios de planificación del alta oportunos y adecuados para una transición fluida desde un hospital, un centro de enfermería especializada o un centro de rehabilitación al hogar del miembro.  La planificación del alta puede incluir, entre otros, lo siguiente:

  • Servicios de salud a domicilio
    • Visitas de enfermería especializada
    • Fisioterapia
    • Terapia ocupacional
    • Terapia del habla
  • Servicios ambulatorios: fisioterapia, terapia ocupacional y terapia del habla
  • Equipo médico duradero (incluidos los suministros)
  • Cualquier otra necesidad urgente relacionada con el alta para facilitar la transición del miembro de regreso a su hogar

Envíe las solicitudes de autorización previa a Community al menos entre 24 y 48  horas antes del alta de un hospital, centro de enfermería especializada o centro de rehabilitación. 

Si un miembro recibe el alta fuera del horario de atención o durante el fin de semana, los proveedores deben enviar las solicitudes de planificación del alta el siguiente día hábil.  Se revisan todas las autorizaciones de alta a fin de evaluar el tratamiento inicial.

Para continuar con el tratamiento y los servicios después de la autorización de alta, se requieren nuevas órdenes médicas del Médico de Atención Primaria (PCP) o del especialista del miembro. Estas solicitudes deben enviarse al número de fax correspondiente para solicitudes de autorización previa. 

  • Complete el formulario de solicitud de autorización previa estándar de Texas o el formulario de autorización previa preferido de Community.
  • Adjunte la orden de alta del hospital (receta firmada, documentación de alta, orden electrónica o verbal y Título 19). Incluya los códigos ICD-10, CPT o HCPCS junto con la frecuencia, la duración y la cantidad de visitas que se solicitan.
  • Para los miembros que se trasladan de un hospital de cuidados agudos a un Hospital de Cuidados Agudos Prolongados (LTAC) o a un Centro de Enfermería Especializada (SNF):
    • Envíe la solicitud por fax (formulario PA y órdenes de traslado con información clínica) al: 713-295-2284
  • Para los miembros que se trasladan de un hospital de cuidados agudos, un LTAC o SNF a su hogar (lugar de residencia):
    • Envíe la solicitud por fax (formulario PA y órdenes de alta con información clínica) al: 713-848-6940
  • Envíe por fax las solicitudes de autorización de salud conductual al: 713-576-0932

Todas las solicitudes de autorización para la planificación del alta siguen los procesos y procedimientos establecidos relacionados con la elegibilidad, los beneficios, la necesidad médica y otros requisitos reglamentarios.

  • Home Health Services
    • Skilled Nurse Visits
    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
  • Outpatient Services – Physical Therapy, Occupational Therapy, Speech Therapy
  • Durable Medical Equipment (including supplies)
  • Any other urgent discharge needs for the Member’s transition back into the home setting

Please submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility. 

If a Member is discharged during non-business hours and/or the weekend, Providers should submit discharge planning requests the following business day.  All discharge authorizations are reviewed for evaluation and initial treatment.

For a continuation of treatment and services after discharge authorization, new physician orders from the Member’s PCP or Specialist are required. These requests must be submitted to the appropriate fax number for prior authorization requests. 

  • Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
  • Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
  • For Members transitioning from an Acute hospital to LTAC or SNF:
    • Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
  • For Members transitioning  from an Acute hospital, LTAC or SNF to Home (place of residence):
    • Fax request (PA form and discharge orders with clinical information  to: 713.848.6940
  • Fax Behavioral Health authorization requests to: 713.576.0932

All discharge planning authorization requests follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.

Si una solicitud de autorización no cumple con la necesidad médica, un director médico revisará la solicitud.

Community enviará una notificación por fax al proveedor solicitante con la oferta de una revisión entre pares.

Plazos para la revisión entre pares:

Al menos un día hábil antes de emitir una determinación desfavorable en una revisión prospectiva (previa al servicio/ambulatoria) de la utilización.

Al menos cinco días hábiles antes de emitir una determinación desfavorable en una revisión retrospectiva.

Antes de emitir una determinación desfavorable en una revisión simultánea (hospitalaria) o en una revisión posterior a la estabilización.

Para solicitar una discusión entre pares, llame al 713-295-2319.

Para la versión en español, haga clic aquí.

What is a prior authorization?

(Medicare) Prior authorization (sometimes referred to as pre-certification or pre-notification) determines whether non-emergent medical treatment is medically necessary, is compatible with the diagnosis, if the Member has benefits, and if the requested services are to be provided in the appropriate setting.

Prior authorization is not a guarantee of payment. Regardless of whether a Provider obtained the required prior authorization, Community Health Choice must process a Provider’s claim according to eligibility, contract limitations, benefit coverage guidelines, applicable State or Federal requirements, National Correct Coding Initiative (NCCI) edits, Texas Medicaid Provider Procedures Manual (TMPPM) and other program requirements, as applicable.

Click here to review the Annual PA Statistics for 2025.

Click here to review the Annual PA Statistics for 2024. 

Annual PA Metrics 2025

Please contact us if you have questions or need assistance with prior authorizations.

Monday – Friday
8:00 a.m. – 5:00 p.m.

On certain holidays, calls will be handled by our automated phone system.

Phone
713.295.5007 or 1.833.276.8306

Website
https://provider.communityhealthchoice.org/resources/

Email

Toll-Free: 1.833.276.8306
TDD Number for Hearing Impaired 7-1-1

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Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.

  • Pharmacy Authorizations
  • Vision Authorizations
  • Dental (over 21)
  • For Medical/Acute Authorizations, Community accepts prior authorization requests via the following methods:
  • For Behavioral Health Authorizations, Community accepts prior authorization requests via the following methods:
    • Community Health Choice secure provider portal
    • Fax: 713.576.0932 (Inpatient)
    • Fax: 713.576.0939 (Outpatient)

Providers must submit the Prior Authorization Request Form, which you can view and download here.  The form must include the following information:

  • Member Name
  • Member Date of Birth
  • Member Medicaid/CHIP Identification Number
  • Requesting Provider Name and National Provider Identifier (NPI)
  • Servicing Provider Name and NPI
  • Requested Service
  • Current Procedures Terminology (CPT) Codes Requested
  • Number of Units Requested
  • Dates of Service
  • In Network Requesting Provider’s Dated Signature

For Transplant Prior Authorization Requests and Clinical Submission, Community accepts prior authorization requests via the following methods:

Click here for a list of requirements for Transplants.

Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:

  • Peer-reviewed, published medical journals.
  • Evidence-based consensus statements
  • Practice guidelines/standards from professionally recognized health care organizations
  • Evidence-based research reviews of a particular topic/technology

Community Health Choice (Community)’s Medical Review Guidelines (MRGs) are used when there is an absence of any applicable Medicare statutes, regulations, National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) describing coverage criteria.

Community’s review guidelines are applied in the following order:

  • Evidence of Coverage and Benefits
  • Federal regulations, statutes, and contract requirements
  • NCDs, LCDs
  • MRGs
  • InterQual
– MRG: Elevidys
– MRG: Trastuzumab
– MRG: Rituximab
– MRG: Bevacizumab
– MRG: Aflibercept
– MRG: Saphnelo
– MRG: Vabysmo
– MRG: Adzynma
– MRG: Amondys
– MRG: Lamzede
– MRG: Pombiliti
– MRG: Sevenfact
– MRG: Viltepso
– MRG: Vyjuvek
– MRG: Tocilizumab
– MRG: Lucentis
– MRG: Zymfentra
– MRG: Leqembi
– MRG: Kisunla
– MRG: Krystexxa
– MRG: Cabotegravir
– MRG: Lenacapavir
 
To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.

Community issues a determination within the following timeframes according to state regulatory requirements.

Prospective Review

  • Urgent
    As soon as possible based on the clinical situation, but no later than 72 hours from receipt of a request for a Utilization Management (UM) determination
  • Routine
    Within 7 calendar days from the receipt of a request for a UM determination
  • Inpatient
    Within 24 hours from the receipt of a request for a UM determination

Concurrent Review

Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.

Retrospective Review

Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.

Community will administratively deny a claim if the Provider does not obtain an authorization prior to rendering services to a Member.  In no event will a Member be financially responsible for payments arising for such services, except for applicable Member expenses as may be required under a benefit plan/program.

Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting.  Discharge planning may include, but not limited to the following:

  • Home Health Services
    • Skilled Nurse Visits
    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
  • Outpatient Services – Physical Therapy, Occupational Therapy, Speech Therapy
  • Durable Medical Equipment (including supplies)
  • Any other urgent discharge needs for the member’s transition back into the home setting

Please ensure to submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility. 

If a Member is discharged during non-business hours and/or weekend, Providers should submit discharge planning requests the following business day.  If necessary, all discharge authorizations will be reviewed for evaluation and initial treatment.

For a continuation of treatment and services after discharge authorization, new physician orders from Member’s PCP or Specialist will be required. These requests must be submitted to the appropriate fax number for prior authorization requests. 

  • Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
  • Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
  • For members transitioning from an Acute hospital to LTAC or SNF:
    • Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
  • For members transitioning  from an Acute hospital, LTAC or SNF to Home (place of residence):
    • Fax request (PA form and discharge orders with clinical information  to: 713.848.6940
  • Fax Behavioral Health authorization requests to: 713.576.0932

All discharge planning authorization requests will follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.

If an authorization request does not meet medical necessity, a Medical Director will review the request.

Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.

Peer to Peer Timeframes:

  • No less than one working day prior to issuing a prospective (pre-service/outpatient) utilization review adverse determination.
  • No less than five working days prior to issuing a retrospective review adverse determination.
  • Prior to issuing a concurrent (inpatient) or post stabilization review adverse determination or post-stabilization review adverse determination.

To request a Peer-to-Peer discussion, please call 713.295.2319.

Para la versión en español, haga clic aquí.

What is a prior authorization?

Prior authorization (sometimes referred to as pre-certification or pre-notification) determines whether non-emergent medical treatment is medically necessary, is compatible with the diagnosis, if the Member has benefits, and if the requested services are to be provided in the appropriate setting.

Prior authorization is not a guarantee of payment. Regardless of whether a Provider obtained the required prior authorization, Community Health Choice must process a Provider’s claim according to eligibility, contract limitations, benefit coverage guidelines, applicable State or Federal requirements, National Correct Coding Initiative (NCCI) edits, Texas Medicaid Provider Procedures Manual (TMPPM) and other program requirements, as applicable.

Click here to review the Annual PA Statistics for 2025

Click here to review the Annual PA Statistics for 2024

Click here to review the Annual PA Statistics for 2021

Annual PA Metrics 2025

Please contact us if you have questions or need assistance with prior authorizations.

Monday – Friday
6:00 a.m. – 6:00 p.m.

Saturday/Sunday/Holidays
9:00 a.m – 12:00 p.m.

Phone
713.295.6704 or 1.855.315.5386

Website
https://provider.communityhealthchoice.org/resources/

Email

Local: 713.295.6704
Toll-Free 1.855.315.5386
TDD Number for Hearing Impaired 7-1-1

Monday through Friday (excluding State-approved holidays)

8:00 a.m. to 5:00 p.m.

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What is HB 3459?

  • This Bill prohibits an Health Maintenance Organization (HMO) that uses Prior Authorizations from requiring a provider to obtain a Prior Authorization for a service, if the Plan approved or would have approved 90% of the Prior Authorization requests submitted by that provider within the most recent six month evaluation period.

What program does this impact?

  • This only applies to Health Insurance Marketplace.

How will this work for Providers?

  • Community will “Gold Card” all providers who have a 90% approval rating on their prior authorization requests for the previous six months
    • Gold Card entails not having to request prior authorizations for treatment
    • Gold Card lasts at least six months after which we may review for renewal
  • The look back period for Gold Card will begin on January 1, 2022 through June 30, 2022.
  • After June 30, 2022 Community will conduct analysis and notify providers of their Gold Card status
  • Gold Card status will commence on October 1, 2022

Where can I find the Prior Authorization Code List?

Click here to view code list

*Please note this is subject to change as we await for additional information from the Texas Department of Insurance and HB 3459 continues to evolve.

August 24, 2026

July 22, 2026

June 17, 2026

May 20, 2026

March 23, 2026

January 25, 2026

December 25, 2026

November 25, 2025

October 25, 2025

September 23, 2025

August 18, 2025

July 15, 2025

June 26, 2025

April 22, 2025

March 21, 2025

January 23, 2025

December 20, 2024

November 22, 2024

October 24, 2024

September 20, 2024

August 21, 2024

July 22, 2024

June 25, 2024

April 25, 2024

April 18, 2024

March 22, 2024

February 25, 2024

January 24, 2024

December 18, 2023

November 25, 2023

October 25, 2023

September 26, 2023

August 23, 2023

July 21, 2023

June 26, 2023

May 26, 2023

April 24, 2023

March 24, 2023

February 27, 2023

January 26, 2023

December 27, 2022

November 25, 2022

August 19, 2022

July 26, 2022

June 17, 2022

May 16, 2022

Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.

  • Pharmacy Authorizations
  • Vision Authorizations
  • For Medical/Acute Authorizations, Community accepts prior authorization requests via the following methods:
  • For Behavioral Health Authorizations, Community accepts prior authorization requests via the following methods:
    • Community Health Choice secure provider portal
    • Fax: 713.576.0932 (Inpatient)
    • Fax: 713.576.0930 (Outpatient)

Providers must submit the Prior Authorization Request Form, which you can view and download here.  The form must include the following information:

  • Member Name
  • Member Date of Birth
  • Member Medicaid/CHIP Identification Number
  • Requesting Provider Name and National Provider Identifier (NPI)
  • Servicing Provider Name and NPI
  • Requested Service
  • Current Procedures Terminology (CPT) Codes Requested
  • Number of Units Requested
  • Dates of Service
  • In Network Requesting Provider’s Dated Signature

For Glucagon like peptide-1 (GLP-1) Prior Authorization Requests and Clinical Submission, starting 5/1/2026, Community will only accept GLP-1 prior authorization requests on this form submitted via fax at 713.848.6949

For Transplant Prior Authorization Requests and Clinical Submission, Community accepts prior authorization requests via the following methods:

Click here for a list of requirements for Transplants.

Community Health Choice (Community) has internal clinical guidelines called Medical Review Guidelines (MRGs) that function as one of the sets of guidelines used for medical necessity determinations and coverage decisions. Our MRGs are evidence-based guidelines from:

  • Peer-reviewed, published medical journals.
  • Evidence-based consensus statements
  • Practice guidelines/standards from professionally recognized health care organizations
  • Evidence-based research reviews of a particular topic/technology

Community Health Choice (Community)’s Medical Review Guidelines (MRGs) are used when there is an absence of any applicable statutes or regulations describing coverage criteria.

Community’s review guidelines are applied in the following order:

  • State/Federal guidelines and Contract Requirements
  • Evidence of Coverage and Benefits
  • MRGs
  • InterQual
– MRG: ABA Services
– MRG: Aflibercept
– MRG: Pegfilgrastim
– MRG: Cabenuva
– MRG: Zynteglo
– MRG: Trogarzo
– MRG: Saphnelo
– MRG: Vabysmo
– MRG: Adzynma
– MRG: Amondys
– MRG: Lamzede
– MRG: Pombiliti
– MRG: Sevenfact
– MRG: Viltepso
– MRG: Vyjuvek
– MRG: Tocilizumab
– MRG: Lucentis
– MRG: Zymfentra
– MRG: Leqembi
– MRG: Kisunla
– MRG: Krystexxa
– MRG: Cabotegravir
– MRG: Lenacapavir
 
To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.

Community issues a determination within the following timeframes according to state regulatory requirements.

Prospective Review

  • Emergency Medical or Emergency Behavioral Conditions do not require prior authorization
  • Urgent – As soon as possible based on the clinical situation, but no later than one business day from receipt of a request for a Utilization Management (UM) determination
  • Routine – Within three business days from the receipt of a request for a UM determination
  • Inpatient – Within one business day from the receipt of a request for a UM determination
  • Post-hospitalization or life-threatening conditions – within one hour from the receipt of a request

Concurrent Review

Community issues the determination for reduction or termination of a previously approved course of treatment early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs, but no longer than two business days.

Retrospective Review

Based on the Retrospective Review Policy for authorizations, if certain conditions are met Community will issue a determination, Community will issue a determination within 30 calendar days from the receipt of request for a retrospective UM determination for a service that Provider has already rendered and for which Provider has not submitted a claim. Fax requests for Retrospective Review with supporting documentation to 713.576.0937.

Pharmacy

  • Urgent – if prescribing Provider calls Community, Community will provide prior authorization approval or denial immediately.
  • Routine – Community will notify the prescribing Provider of prior authorization denial or approval no later than 24 hours after receipt.
  • If Community cannot provide response to a prior authorization request within 24 hours after receipt or the prescriber is unavailable to make request (after-hours) and dispensing pharmacist determines it is an emergency, Community will allow the pharmacy to dispense a 72-hour supply of the drug.

Community will administratively deny a claim if the Provider does not obtain an authorization prior to rendering services to a Member.  In no event will a Member be financially responsible for payments arising for such services, except for applicable Member expenses as may be required under a benefit plan/program.

Community provides timely and appropriate discharge planning services for a seamless transition from a hospital, skilled nursing or rehabilitation facility to the Member’s home setting.  Discharge planning may include, but not limited to the following:

  • Home Health Services
    • Skilled Nurse Visits
    • Physical Therapy
    • Occupational Therapy
    • Speech Therapy
  • Outpatient Services – Physical Therapy, Occupational Therapy, Speech Therapy
  • Durable Medical Equipment (including supplies)
  • Any other urgent discharge needs for the member’s transition back into the home setting

Please ensure to submit prior authorization requests to Community at least 24 to 48 hours prior to discharge from a hospital, skilled nursing or rehabilitation facility. 

If a Member is discharged during non-business hours and/or weekend, Providers should submit discharge planning requests the following business day.  If necessary, all discharge authorizations will be reviewed for evaluation and initial treatment.

For a continuation of treatment and services after discharge authorization, new physician orders from Member’s PCP or Specialist will be required. These requests must be submitted to the appropriate fax number for prior authorization requests. 

  • Complete the Texas Standard Prior Authorization request form or Community’s Preferred Prior Authorization form.
  • Attach discharge order from the hospital (signed script, discharge paperwork, electronic or verbal order, and Title 19). Include ICD-10 code(s), CPT and/or HCPCS code(s) with frequency, duration and amount of visits or visits being requested.
  • For members transitioning from an Acute hospital to LTAC or SNF:
    • Fax request (PA form and transfer orders with clinical information) to: 713.295.2284
  • For members transitioning  from an Acute hospital, LTAC or SNF to Home (place of residence):
    • Fax request (PA form and discharge orders with clinical information  to: 713.848.6940
  • Fax Behavioral Health authorization requests to: 713.576.0932

All discharge planning authorization requests will follow established processes and procedures related to eligibility, benefits, medical necessity, and other regulatory requirements.

If an authorization request does not meet medical necessity, a Medical Director will review the request.

Community will send a fax notification to the requesting Provider with the offer of a Peer-to-Peer.

Peer to Peer Timeframes:

  • No less than one working day prior to issuing a prospective (pre-service/outpatient) utilization review adverse determination.
  • No less than five working days prior to issuing a retrospective review adverse determination.
  • Prior to issuing a concurrent (inpatient) or post stabilization review adverse determination or post-stabilization review adverse determination.

To request a Peer-to-Peer discussion, please call 713.295.2319.

Health Insurance Marketplace
By mail:
Community Health Choice 2636 South Loop West, Ste. 125, Houston, Texas 77054
By email:
By phone:
  • Member Services: 713-295-6704 or 1-855-315-5386  (Monday – Friday; 8:00 a.m. – 5:00 p.m.) Information is available in English and Spanish. Call Community Health Choice to get an interpreter.
  • 24-hour Nurse Help line: 1-800-835-2362
  • Care Management: 713-295-2303 or 1-855-315-5386
  • Provider Services: 713-295-6704 Phone, 713-295-2283 Fax
  • Envolve Vision:  1-800-334-3937
  • Behavioral Health/Substance Abuse: 1-855-539-5881
 
Medicaid/CHIP
By mail:
Community Health Choice 2636 South Loop West, Ste. 125, Houston, Texas 77054
By email:
By phone:
  • Community General Information: 713-295-2222 or 1-877-635-6736 (Monday through Friday 7:00 a.m. to 7:00 p.m.)
  • Member Services: 713-295-2294
Medicare
By phone:
  • Community General Information: 713.295.5007 or 1.833.276.8306 (October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm. On certain holidays your call will be handled by our automated phone system.)

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“Community Health Choice is always there to answer my questions and help me and my family with our medical needs. I truly appreciate and value their customer support and service.”

– Cecily
Member of Community Health Choice