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Prior Authorization of Health-Care Services

Superior members have access to all Medicaid and CHIP covered benefits that are medically necessary health-care services. Some of these services need to be reviewed before the service is provided to make sure the service is appropriate and medically necessary. This review is called prior authorization, and is made by doctors, nurses and other health-care professionals. If a prior authorization request cannot be approved based on medical necessity, you will receive a letter with the reason why the prior authorization request was not approved. This is called a denial. You can ask Superior to review the denial again. This is called an appeal.

A list of the Medicaid and CHIP covered services that require prior authorization may be found by visiting:

Health-care providers are responsible for submitting prior authorization requests. These requests can be submitted by phone, fax or online, using Superior’s Secure Provider PortalYour doctor can also get more information by visiting Superior’s Medicaid and CHIP Prior Authorization Requirements webpage.

Review the information below to learn more about which services may need prior authorization approval before the service is provided.

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. 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. Superior does not offer financial rewards to doctors, nurses or other clinical staff involved in making a utilization review decision. In addition, utilization review policy and criteria do not encourage decisions that may result in members not receiving all medically necessary services.

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.

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 will be denied. You may receive a bill from the provider for those services.

Admission to a hospital for an overnight stay that is not planned does not require prior authorization. Superior’s network hospitals are required to provide notice of the admission to Superior. Your inpatient stay is closely watched to make sure you are getting medically necessary services. 

Pre-scheduled inpatient admissions, such as an elective surgical procedure, must be prior authorized before you are admitted. Your provider will send the prior authorization request to Superior.

Superior covers prescription medications as required by the Texas Vendor Drug Program (VDP). Some medications may require prior authorization and may have clinical prior authorization edits or other limitations related to FDA recommendations. This is to make sure they are safe and effective. Other medically necessary pharmacy services or products are covered to meet VDP guidance.

You may be given a 72-hour emergency supply of a drug that requires prior authorization in certain cases. You can use the following links for outpatient pharmacy clinical edits, quantity limits and non-preferred drugs on the VDP website.

Your provider should submit a prior authorization request with a minimum of five (5) business days before the desired start date of the service. The timeframes for responding to prior authorization requests are listed below:

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

Program

Type of Request

Prior Authorization Notification Timeframe

Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health)

Routine

3 business days

CHIP Routine 2 business days – approval
3 business days – denial
CHIP and Medicaid Urgent/Expedited

72 hours

 

Pharmacy Benefits

Program  Type Prior Authorization Notification Timeframe 
Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health), CHIP Routine, Urgent/Expedited 24 hours

 

Additional time, but no more than 14 calendar days, may be allowed to process therapy, home health and Durable Medical Equipment (DME) prior authorization requests for Medicaid members under 21 years of age.

If necessary to complete the medical necessity review, a request for more clinical information is sent to the provider who submitted the prior authorization request. If the requested information is not received in two (2) business days, a letter is sent to you. The letter will tell you know we have not received the requested information from your provider. If the information is not received within seven (7) calendar days of sending that letter, Superior’s medical director will make a decision with the clinical information available.   

The pre-appeals process for prior authorization requests begins when Superior is unable to approve a prior authorization request for a STAR Health member. 

The member’s provider is contacted to have a peer-to-peer discussion with Superior’s medical director. If the prior authorization request cannot be approved after peer-to-peer discussion, the STAR Health Service Management department notifies the STAR Health member’s Medical Consenter and/or Department of Family and Protective Services (DFPS) staff that additional information is needed to confirm the medical necessity of the request. The pre-appeal process, including the prior authorization decision and notification, is completed within 14 calendar days of the authorization request.

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 units:

  • Centene Company of Texas, LP (License #4167) – Physical and Behavioral Health
  • Texas National Imaging Associates, Inc. (License #5258) – Radiology and Cardiac Imaging
  • Turningpoint Healthcare Solutions, LLC (License #2395464) – Musculoskeletal Surgical Procedures
  • DentaQuest USA Insurance Company, Inc. (License #1786622) – Orthodontic Services (STAR Health)
  • Envolve Pharmacy Solutions, Inc. (License #1774935) – Prescription Services