Prior Authorization Information

Prior Authorization Information

  • Medicaid/CHIP
  • Health Insurance Marketplace
  • Medicare

For Spanish version, click here.

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.

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

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

Email
[email protected]

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 for an accurate and up-to-date list of services that require prior authorization.  The guide may not include all services that require or do not require prior authorization. Please call Provider Services for further information if you are unsure of prior authorization requirements. The list of services is subject to change and will be updated as required. 

Click here to review the Prior Authorization Annual Review Report. 

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:

  • 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

To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical need 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.

If during the preauthorization screening or the initial clinical review of a request there is no clinical information or insufficient clinical information is provided with the request, Community will contact the attending physician, ordering Provider, or facility rendering service requesting the information to request needed information.

  • Community notifies the Provider via fax or telephone call to submit the missing information.
  • If no additional information is received from the Provider, Community will issue an administrative denial.

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 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

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 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.

For Spanish version, click here.

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.

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 for an accurate and up-to-date list of services that require prior authorization.  The guide may not include all services that require or do not require prior authorization. Please call Provider Services for further information if you are unsure of prior authorization requirements. The list of services is subject to change and will be updated as required. 

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

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.

If during the preauthorization screening or the initial clinical review of a request there is no clinical information or insufficient clinical information is provided with the request, Community will contact the attending physician, ordering Provider, or facility rendering service requesting the information to request needed information.

  • Community notifies the Provider via fax or telephone call to submit the missing information.
  • If no additional information is received from the Provider, Community will issue an administrative denial.

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 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

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.

For Spanish version, click here.

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.

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

Click here for an accurate and up-to-date list of services that require prior authorization.  The guide may not include all services that require or do not require prior authorization. Please call Provider Services for further information if you are unsure of prior authorization requirements. The list of services is subject to change and will be updated as required. 

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

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.

If during the preauthorization screening or the initial clinical review of a request there is no clinical information or insufficient clinical information is provided with the request, Community will contact the attending physician, ordering Provider, or facility rendering service requesting the information to request needed information.

  • Community notifies the Provider via fax or telephone call to submit the missing information.
  • If no additional information is received from the Provider, Community will issue an administrative denial.

 

 

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 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

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.

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

 

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

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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 one of the greatest companies that I know. This program gives me hope in our Community.