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Texas Standard Prior Authorization Request Form for Health Care Services Restrictions

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Reminder: The Texas Standardized Prior Authorization Form should not be used as a replacement for Texas Medicaid & Healthcare Partnership (TMHP) required forms. The Texas Standardized Prior Authorization Form is available for provider access, but it must be used as an additional form. This form does not replace current required forms.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.