CSHCN 2009 > Authorizations and Prior Authorizations > Authorization and Prior Authorization Denials

4.6 Authorization and Prior Authorization Denials

Authorization and prior authorization requests that do not contain all of the information necessary for the program to make a determination are denied.

Some of the most common reasons authorizations and prior authorizations are denied is because the request received:

•Is incomplete.

•Is submitted on the wrong form.

•Lacks the necessary documentation.

•Contains inaccurate information.

•Fails to meet the submission deadline.

•Is for an ineligible client, benefit, or provider.

•Is for a client that does not qualify for the health-care benefit requested.

Denied authorization and prior authorization requests may be corrected and resubmitted. Corrected requests must meet authorization and prior authorization submission deadlines to be considered.

Providers dissatisfied with TMHP's decision to deny authorization and prior authorization of services may submit a request for an administrative review to the DSHS-CSHCN Services Program.

Refer to: Section 7.3.5, "Administrative Review for Claims" for information about the administrative review process.