Prior Authorization of Health-Care Services

Prior authorization decisions are made using generally-accepted clinical practices, which include the special needs of each case that may require an exception to the standard. Clinical screening criteria are used to review the medical necessity of the requested service.

The following clinical guidelines are used to make medical necessity decisions, on a case-by-case basis, based on each member’s health status, as appropriate:

• Federal and State Laws and Rules
• Interqual® criteria
• Proprietary clinical guidelines
• Texas Medicaid Provider Procedures Manual (Medicaid)

To find clinical policy screening criteria for certain service types, visit Superior’s Clinical Policy webpage.

If the medical necessity of a prior authorization cannot be confirmed by clinical staff, a Texas-licensed physician/medical director reviews the case. This review includes the option for a peer discussion with the rendering/ordering provider who ordered the service before making any adverse determination.

At least once a year, a review is completed to make sure all clinical reviewers follow the same process in clinical case reviews. Financial rewards are not offered to doctors, nurses or other clinical staff responsible for making a utilization review decision. In addition, utilization review policy and criteria do not allow decisions that may result in members not receiving all medically necessary services.

Physical and behavioral health emergencies, life threatening conditions and post-stabilization services do not require prior authorization. 

Except for emergency services, post-stabilization services, and services provided to you during an approved inpatient admission, all services from an out-of-network provider must be prior authorized. Claims for services from out-of-network providers that are not approved before the service is given may be denied.

Urgent or emergent admission to a hospital for an overnight stay does not require prior authorization. However, hospitals are required to provide notice of the admission within one business day of an admission. Your inpatient stay is reviewed during your inpatient stay, to make sure you are getting medically necessary and appropriate services in the hospital. 

Priorscheduled inpatient admissions, referred to as “elective” (vs. urgent or emergent) admissions, must be prior authorized before you are admitted. An example of an elective admission is a surgical service or procedure that requires an inpatient admission, but can be scheduled well in advance of the surgery or procedure.  Your provider is responsible to request the prior authorization for the admission. 

Superior covers prescription medications approved by the Texas Vendor Drug Program (VDP) for the Medicaid and CHIP Programs. Some medications may require prior authorization and may have clinical prior authorization edits or other limitations related to federal Food and Drug Administration (FDA) recommendations. This is to make sure they are safe and effective. Other medically necessary pharmacy services or products are covered if included on the  VDP approved list.

In certain cases, you may be given a 72-hour emergency supply of a drug that requires prior authorization. You can use the following links for outpatient pharmacy clinical edits, quantity limits and non-preferred drugs on the VDP website.  A non-preferred drug is a medication that has been determined to have another drug available that is clinically equivalent. 

• Clinical Edits, found on Superior’s Clinical Prior Authorization webpage.
• Quantity Limits, found on Superior’s Pharmacy webpage, under Pharmacy Resources.
• Non-preferred drugs, found on Texas VDP Preferred Drug List.

A reasonable opportunity for physician peer discussion (Peer to Peer) is offered prior to adverse determination on all prior authorization requests, including all urgent, standard, and Medicaid incomplete prior authorization requests.

Standard Prior Authorization Request - Incomplete or Insufficient Documentation

• Medicaid prior authorization requests must contain all Essential Information
  • Essential Information is prescribed in HHSC’s UMCM, Chapter 3.22, II. A., and includes all elements below.
    • Member name, Medicaid ID number and date of birth
    • Requesting and rendering/servicing provider name, National Provider Identifier (NPI), and Tax Identification Number (TIN)
    • Service requested - Current Procedural Terminology (CPT), Healthcare Common Procedure (HCPCS)
    • Service requested start and end date(s)
    • Quantity of service units requested
  • All essential information must be included on each PA request.
  • Prior authorization requests are rejected/returned back to the provider for resubmission, if one or more essential information elements are missing, invalid or illegible.
    • The deficiency in the PA request is communicated to the provider with the request for resubmission of the PA request.
• Medicaid prior authorization requests must include Complete and Sufficient Clinical Information
  • An incomplete Medicaid prior authorization request is a request in which clinical information/documentation is incomplete or insufficient.
    • Medical Management will communicate the request to supply the missing but required clinical information to proceed with the medical necessity review through faxed request to the provider’s office. Providers may also receive a phone call requesting missing clinical information, as necessary and appropriate.
    • The written or verbal notice containing the details of the incomplete/insufficient clinical documentation is delivered to the provider via fax or phone, within three (3) business days after receipt of a prior authorization request containing all essential information.
      • The member/patient receives a written notice of the request for submission of the incomplete clinical information.
    • Providers must supply the requested clinical information/documentation within three (3) business days after the request. If the clinical information/documentation is not received within the required timeframe, the case will be reviewed with the incomplete or insufficient information received with the PA request.
    • The requested clinical should be faxed to Medical Management, using the appropriate fax number for the service for which authorization is requested. 
      • Medicaid Prior Authorization Fax Numbers:
        • Physical Health: 1-800-690-7030
        • Behavioral Health: 866-570-7517
        • Clinician Administered Drugs (CAD): 1-866-683-5631
        • Prescription Drugs: 1-833-423-2523
        • Radiology and Cardiac Imaging: 1-800-784-6864
        • Musculoskeletal Surgical Procedures: 1-833-409-5393
        • Orthodontics (STAR Health): 1-888-313-2883
    • Medical Management provides notice of the determination of approval or denial of the prior authorization request within three business days after receipt of a complete prior authorization request.

Demographic and Clinical Information

• To ensure that the medical necessity review of a prior authorization request can be timely processed for determination, the following information must be included with each prior authorization request:
  • Member information (Member name, Member DOB, Member Medicaid or CHIP ID number); and
  • Provider information (Rendering provider name, NPI, TIN; and
  • Physician signature/Physician order; and
  • Specification and description of service, supply, equipment, or CAD procedural/service code(s) and description (CPT, HCPC, NDC); and
  • Pertinent diagnosis/conditions that relate to the need for the service (ICD-10); and
  • Objective clinical information necessary to support medical necessity for the requested service; and
  • Start and end date(s) of service; and
  • Frequency and duration
• Depending on the request, specific clinical documentation and information may also be required to complete the medical necessity review.

Incomplete Prior Authorization Requests 

• If a prior authorization request does not include the demographic and/or clinical information necessary to complete the medical necessity review of the request, two (2) phone call attempts are completed to obtain the missing documentation/information.
• If the required information is not received as required in the request, the prior authorization request is forwarded to a Medical Director for determination, based on the clinical information available.

In most cases, your provider should submit a prior authorization request five (5) business days before the desired start date of the service. 

The timeframes required to provide a decision in response to a prior authorization request is listed below, for different types of prior authorization requests:

Physical Health Services, Supplies, Equipment, Behavioral Health Services, Clinician Administered Drugs (CAD)

Outpatient Pharmacy Services

Superior HealthPlan is contracted with several Texas licensed Utilization Review Agents (URAs) to conduct utilization reviews for applicable prior authorization requests. These include the following Texas licensed Utilization Review Agents:

• Centene Company of Texas, LP (License #4167) – Physical Health, Behavioral Health and Clinician Administered Drugs
• Texas National Imaging Associates, Inc. (License #5258) – Radiology Services, Cardiac Imaging, and Physical, Occupational and Speech Therapy Services
• Turningpoint Healthcare Solutions, LLC (License #2395464) – Musculoskeletal Surgical Procedures and Pain Management Services
• DentaQuest USA Insurance Company, Inc. (License #1786622) – Orthodontic Services (STAR Health)
• Centene Pharmacy Solutions, Inc. (License #1774935) – Prescription Services
• New Century Health (License # 1777359) – Oncology Services