MEDICAID PROVIDER NOTICE: Standard Prior Authorization Request - Incomplete or Insufficient Documentation
Date: 04/17/21
Effective April 2021, Superior HealthPlan implemented the new Medicaid managed care program requirements related to standard prior authorization (PA) requests and physician peer discussions prior to adverse determination. This implementation is pursuant to the passage of Senate Bill 1207, the associated statutory requirements in Chapters 531 and 533 of the Texas Government Code, and the managed care contractual requirements defined in the Texas Health and Human Services (HHS) Uniform Managed Care Manual.
A summary of the new Incomplete Prior Authorization Process published by HHS in the Uniform Managed Care Manual (UMCM), Chapter 3.22, is included below. Note that the Incomplete PA process is not applicable for urgent prior authorization requests.
- Medicaid prior authorization request 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.
- Essential Information is prescribed in HHSC’s UMCM, Chapter 3.22, II. A., and includes all elements below:
- “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. Note the STAR Health specific exceptions for faxing clinical information for STAR Kids PDN and PT, OT, ST services, denoted in the listing below:
- STAR, STAR+PLUS, STAR Health, STAR Kids Prior Authorization FAX NUMBERS:
- Physical Health Acute Care Services: 1-866-918-2268
- Outpatient Durable Medical Equipment: 1-800-521-8836
- Behavioral Health Services: 1-866-570-7517
- Biopharmacy Services: 1-866-683-5631
- STAR Kids (ONLY) PDN and PT, OT, ST FAX NUMBERS:
- STAR Kids Private Duty Nursing (PDN): 1-844-218-1157
- STAR Kids and PT, OT, ST: 1-844-218-1157
- STAR, STAR+PLUS, STAR Health, STAR Kids Prior Authorization FAX NUMBERS:
- 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.
- “Reasonable opportunity for physician peer discussion (Peer to Peer)” is offered prior to adverse determination on all prior authorization requests, including incomplete prior authorization requests.