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Haga clic aquí para volver al sitio de miembros.
Para la versión en español, haga clic aquí.
(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:
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
[email protected]
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 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
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:
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:
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:
Lack of Information
When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
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.
| Service | Initial Authorization | Re-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 Nursing | Initial 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. |
| DME | Prior 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
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
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:
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.
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.
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.
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:
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
[email protected]
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.
Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.
Prior Authorization Submission
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:
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:
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:
Lack of Information
When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
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.
| Service | Initial Authorization | Re-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 Nursing | Initial 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. |
| DME | Prior 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
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
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:
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.
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.
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.
(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:
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
[email protected]
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 review the Prior Authorization Annual Review Report.
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
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:
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:
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:
Lack of Information
When Community receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
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.
| Service | Initial Authorization | Re-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 Nursing | Initial 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. |
| DME | Prior 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. |
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information:
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
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
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:
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.
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.
To request a Peer-to-Peer discussion, please call 713.295.2319.
Para la versión en español, haga clic aquí.
(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.
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
[email protected]
Toll-Free: 1.833.276.8306
TDD Number for Hearing Impaired 7-1-1
Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information:
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:
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:
Community issues a determination within the following timeframes according to state regulatory requirements.
Prospective Review
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:
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.
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.
To request a Peer-to-Peer discussion, please call 713.295.2319.
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.
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
[email protected]
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.
Click here to view the January 1, 2025 catalog
Click here to view the October 15, 2024 catalog
Click here to view the October 1, 2024 catalog
Click here to view the June 2024 catalog
Click here to view the May 1, 2024 catalog
Click here to view the April 1, 2024 catalog
Click here to view the 2024 catalog
Click here to view the 2023 catalog
What is HB 3459?
What program does this impact?
How will this work for Providers?
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.
Click here to view.
Except for emergencies, Community requires prior authorization for all services performed by a non-participating Provider.
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information:
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:
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:
Community issues a determination within the following timeframes according to state regulatory requirements.
Prospective Review
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
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:
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.
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.
To request a Peer-to-Peer discussion, please call 713.295.2319.
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
Medicaid
Health Plan
04/01/2027
Marketplace
Health Plan
03/01/2027
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