Rendering Provider Information No Longer Classified as Critical Data Element to Initiate Standard Prior Authorization Requests

Date: 03/24/23

Texas Health and Human Services Commission (HHSC) has specific processes and timelines when prior authorization requests contain insufficient or inadequate documentation. Superior HealthPlan, as a Managed Care Organization (MCO), must abide by these requirements and ensure providers submit the correct prior authorization information needed.

In 2021, HHSC considered adding the rendering provider information to the list of essential information required to submit a prior authorization request. Following a comprehensive review, HHSC will no longer consider a missing rendering provider name or NPI as a permissible reason to deny a prior authorization request without allowing the requesting provider on record an opportunity to submit the missing information or offer the member a right to an MCO appeal/state fair hearing process. This means that a Superior HealthPlan (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, STAR+PLUS Medicare-Medicaid Plan (MMP) prior authorization request cannot be rejected solely for the reason of missing the rendering provider information (if different from a requesting provider) on submission.

Information on Superior’s prior authorization requirements can be found in our provider manuals found on Superior’s Training and Manuals webpage.

For additional questions, please contact your local Account Manager.