4.3 Prior Authorizations

Providers must submit prior authorization requests on a CSHCN Services Program-approved form. If a form is not available for a specific service, providers must submit the request using the “CSHCN Services Program Authorization and Prior Authorization Request,” on page B‑110 and follow the guidelines and requirements listed in the chapter for that service. Only complete prior authorization requests will be considered. Incomplete requests are denied.

Prior authorization requests must be submitted and approved before the service is provided. However, if the service is provided after business hours (business hours are Monday through Friday, from 8 a.m. to 5 p.m., Central Time), on a weekend, or on a holiday (see list in Section 4.4 below), then the prior authorization request may be submitted on the next business day.

Providers should allow three business days to receive a response to an authorization or prior authorization request.

If a provider requests prior authorization after admitting a client to an inpatient facility on a nonemergency basis, the prior authorization will only be valid from the date of the approval through the discharge date.

If a client requires a service that exceeds policy limitations, providers may request prior authorization with documentation of medical necessity.

If a client requires a service that has diagnosis restrictions, providers may request prior authorization with documentation of medical necessity for diagnoses not listed in the policy.

Claims submissions must include the prior authorization number in the appropriate field.

Refer to:

Section 5.7, “Claims Filing Instructions,” on page 5‑24 for claims filing instruction details.

Important: The Program does not grant extensions to these deadlines to allow providers to complete or correct and resubmit their prior authorization requests.

Exception: The prior authorization requirement may be waived if the client’s eligibility had not been determined by the time TMHP received the request. Claims for these services must be received within 95 days of the eligibility add date and must include a completed request for prior authorization, along with all other applicable documentation.