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December 2016 Texas Medicaid Provider Procedures Manual

Section 5: Fee‑for‑Service Prior Authorizations : 5.5 Prior Authorization Submission Methods : 5.5.4 Radiology Prior Authorizations Through eviCore : Prior Authorizations to eviCore by Fax, Telephone, or Mail
When submitting radiology prior authorization requests to eviCore by fax or mail, providers must use the approved Radiology Prior Authorization Request Formon the TMHP website at
Telephone: 1-800-572-2116
Fax: 1-800-572-2119
Mail: Texas Medicaid & Healthcare Partnership
730 Cool Springs Blvd., Suite 800
Franklin, TN 37067

Texas Medicaid & Healthcare Partnership
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