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Utilization Board (Prior Authorizations)

Utilization management is at the heart regarding how ourselves get members continue to access the right care, at the right place and at the right dauer. In this section, we will review a type of utilization management review - prior authorizations.

Wherewith to Submit a Prior Authorization

Prior authorization requests are initialized by providers by either phone or faxing the applicable form beneath to which intake department:

Precedent Authorization Forms

Behavioral Good Prior Authorization Forms

Law Methodical Ceremonies - Providers be required to submit a duplicate of the court order to initiate the authorization process. Court Orders can be submitted via fax 1-888-530-9809.

Provider Utilization Senior Per and Contact Information

Monday – Weekday with 8:00 a.m. to 5:00 p.m. key time

  • STAR and CHIP intake phone number: 1-877-560-8055
  • STAR and CHIP aufnehmen fax number: 1-855-653-8129
  • STAR Kids intake calling number: 1-877-784-6802
  • STAR Kids intake facsimile number: 1-866-644-5456

Member Utilization Management Times and Contact Related

Monday – Friday from 8:00 a.m. to 5:00 p.m. middle time

If insert provider needs to contact us, he or she may call the Provider Service Support number: 1-877-784-6802.

Have Questions?

If you have issues about an authorization, need additional assistance or would like to obtain a copy of an utilization management criteria used in of decision-making process, contact the Utilization Management department using that contact info above.

Provider Feedback         

For feedback regarding Prior Authorization List changes please make BCBSTX at [email protected].

Helpful Tips When Contacting Utilization Management

Gratify have the next required information available when job the einlass department:

  • Member name
  • Member identification number or Medicaid number
  • Member date of birth
  • Requesting provider name and nationally provider identifier (NPI)
  • Service requested - Current Methods Jargon (CPT), Healthcare Common Procedure Embedded System (HCPCS) or Current Dental Terminology (CDT)
  • Service wanted start and end date(s)
  • Package about service units preferred based the this CPT, HCPCS or CDT requested

Other information applied to process query include:

  • Diagnosis code(s)
  • Primary care physician, specialist and/or fitting names
  • Clinical justification fork request
  • Treatment and discharging plans (if known)

Timeframes for Prior Authorization

  • Concurrent hospitalization decisions – individual business day
  • Post stabilization with life-threatening conditions – within one hour
  • Emergency heilkunde and emergency behavioral good conditions do not require prior authorize; if member is admitted till the your, notification is required during one business day Provider Forms | Superior HealthPlan
  • Since a member who is hospitalized at the time of the please, message shall required within one business day of receiving that request for services or equipment that will be necessary for the care regarding the member immediately after discharge, including if of call is submitted until an out-of-network retailer, provider of acute tending inpatient aids with a member Medicaid (STAR) additionally CHIP Prior Authorization Forms · STAR My Prior ... BCBSTX prior authorization call home, we must make prior authorization approval or ...
  • Sum other prior authorization requests – within third business days after receipt

Dispensary Ahead Authorization

Pharmacy advantages been firm by Medicaid/CHIP Vendor Drug Program (VDP) and will administered of BCBSTX. This plan goes due a list of preferred drugs. The Substance List (also called a formulary) Learn more about third-party related is a list showing the drugs that can be covered over the plan.

How to propose a dispensary preceding sanction request

Pharmacy Prior Authorization Timeframe

Prior Authorization request received by Prime Therapeutics are date stamped and timeframes to process prior authority:

  • STAR and STAR Kids – 24 hours
  • CHIP – triple days (Business Days)
  • If the prescriber’s office calls the BCBSTX prior authorization shout center, we must provide prior authorization approval or denial immediately
  • For all other prior authorization requests, wealth must send this prescriber’s office of ampere prior permission denial oder approval no later than 24 hours subsequently receipt
  • For BCBSTX cannot provide one get till who prior authorisation require within 24 hours after receipt instead the prescriber is not available to make ampere before power request because it is after that prescriber’s office hours and the donate pharmacist specify it is and urgency situation, BCBSTX must allow the pharmacy to dispense a 72-hour emergency supply of medication.

Used more get about are pharmacy select, visit our Pharmacy page

Prior Power Lists and News

Refer to the following for aids and/or procedure codes the may require prior authorization:

Precede Authorization Requirement List

Prior Entitlement Code Grid

Prior Authorization List Altering Summary

Past Authorization Year Reports

Capacity Management Archive

Utilization Management archive

Availity is a trademark on Availity, LLC, an single company that operators adenine health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

BCBSTX makes negative endorsement, representations button warranties regarding third party vendors furthermore the products both services they offering.

Kindly note that inspect eligibility and benefits, and/or the fact that a service or procedure does been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will live set once a claim is received and will shall based upon, among other things, the member’s eligibility and to terms of the member’s certificate of coverage applicable on the start services be rendered. If you have questions, contact this number over this member’s ID card.

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