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

These include non-elective, inpatient admissions, including those that are subsequent to emergency services and stabilization of the patient, which do not require prior authorization.

All inpatient confinements do require ‘notification’ of the admission no later than the next business day after the date of admission. Following notification of admission, concurrent and/or retrospective utilization review is conducted to confirm the continued medical necessity of the inpatient stay. Facility providers should reference the Notification of Admission and Concurrent Review section on this webpage for additional details and information.

Professional services provided during a medically necessary inpatient admission do not require separate authorization.

Prior authorization is required before the provision of all non-emergent health-care services, supplies, equipment and Clinician Administered Drugs (CAD) delivered by a provider that is not contracted with Superior.

It is the responsibility of the rendering, ordering or referring practitioner to initiate the request for prior authorization for non-contracted provider health care services. Those requests will be reviewed to determine the medical necessity of approving the delivery of care outside of Superior’s contracted provider network, for those situations in which no contracted provider is available to deliver the applicable service. If a contracted provider is available for provision of the requested service, the prior authorization request may be denied with redirection to a contracted provider. 

Requesting providers must initiate a request for prior authorization for non-urgent health-care services prior to delivering the requested service, medical supply equipment or clinician administered drug

It is recommended that prior authorization requests be submitted a minimum of five (5) business days before the desired start date of service. 

Prior authorization requests can be submitted by phone, fax or online through the Secure Provider Portal. 

• Phone Requests
  • Authorization phone requests require subsequent submission of applicable documentation and clinical information to facilitate the medical necessity review of the request.
  • Authorization phone assistance is available on weekdays from 8am – 5pm in all time zones in Texas.
  • To access the phone numbers for inpatient notification and prior authorization for each applicable service type, please refer to the FAX, PHONE, AND SECURE PORTAL DIRECTORY dropdown on this webpage.  
• Fax Requests
  • Providers should include a completed Authorization Request form and all required documentation and clinical information with an authorization request submitted through Fax.
    • For Authorization Request forms for applicable services, visit Superior’s Provider Forms webpage.  
    • Prior authorization request fax numbers for each applicable service type are included under the FAX, PHONE, AND SECURE PORTAL DIRECTORY dropdown on this webpage.
• Secure Provider Portal
  • Providers are encouraged to utilize the Secure Provider Portal for electronic submission of authorization requests.
    • The provider portal includes notation of ‘required fields’ for submission of all necessary information for a complete authorization request.
    • Providers who do not currently have access to the Secure Provider Portal for authorization submissions can create an account by visiting Provider.SuperiorHealthPlan.com.
    • Providers who require training on the appropriate procedures for authorization request entry through the provider portal should contact their Superior Account Manager.
  • The link to the appropriate web portal for submission of applicable authorization requests are included under the FAX, PHONE, AND SECURE PORTAL DIRECTORY dropdown on this webpage.
• Provider Identifiers – Inpatient Notifications and Prior Authorization Requests
  • When submitting a request for prior authorization or to provide notification of an inpatient admission by fax, phone, or Superior’s Secure Provider Portal, the Tax Identification Number (TIN) and National Provider Identifier (NPI) that will be used to bill the claim after the authorized service is provided must be supplied.
  • It is very important that the NPI and TIN supplied for the authorization request is the same NPI and TIN that will be included on the claim.
  • If the provider identifiers in the authorization do not match the provider identifiers on the claim, the claim may be denied even if the authorization request was approved. Providers are required to appeal the denied claim(s) in this situation.
• Screening Criteria
  • Utilization review decisions are made in accordance with generally-accepted clinical practices, taking into account the special circumstances of each case that may require an exception to the standard. Clinical screening criteria are used for the review of 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, and includes the opportunity for a peer discussion with the rendering/ordering provider prior to issuing any adverse determination.
  • At least annually, an assessment is completed to validate the consistency clinical reviewers apply clinical criteria in case reviews. Superior does not financially incentivize physicians or other individuals in utilization review decision making, and Superior utilization management policy and criteria do not encourage decisions that result in underutilization.
  • The following guidelines are utilized to make medical necessity decisions, on a case-by-case basis, based on the information provided on the member’s health status, as applicable:
    • Federal and State Laws and Rules
    • Interqual® criteria
    • Proprietary clinical guidelines
    • Texas Medicaid Provider Procedures Manual (Medicaid)
  • To access clinical policy screening criteria for specific service types, visit Superior’s Clinical Policy and Screening Criteria webpage.
• Reasonable Offer for Physician Peer Discussion Prior to Adverse Determination
  • 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.

*For Medicaid STAR, CHIP and STAR+PLUS (non-STAR+PLUS HCBS Waiver) members

To see resources for services above, please see PRIOR AUTHORIZATION RESOURCES section below.

• Applied Behavioral Analysis (ABA) Services
  • Autism Applied Behavioral Analysis Provider Orientation (PDF)
    
  • Autism Benefit Services Initial/Continued Treatment Plan Template (PDF)
    
  • Autism Benefit Services Request for Initial Evaluation (PDF)

National Imaging Associates:

• Interventional Pain Management
  • NIA: Interventional Pain Management Quick Reference Guide (QRG) (PDF)
  • NIA: Interventional Pain Management Frequently Asked Questions (FAQ) (PDF)
• Diagnostic Imaging (CT, CTA, MRI, MRA, PET) and Cardiac Imaging
  • NIA: High Tech Imaging QRG for Rendering Facilities (PDF)
  • NIA: High Tech Imaging QRG for Ordering Physicians (PDF)
• Genetic and Molecular Testing
  • NIA: Genetic and Molecular Testing Frequently Asked Questions (FAQ) (PDF)
  • NIA: Genetic and Molecular Testing Quick Reference Guide (QRG) (PDF)
• Outpatient Rehabilitative and Habilitative Physical, Occupational, and Speech Therapy Services (*For Medicaid STAR, CHIP and STAR+PLUS [non-STAR+PLUS HCBS Waiver] members)
  • NIA: Physical Medicine (Therapy) Quick Reference Guide (QRG)
  • NIA: Physical Medicine (Therapy) Frequently Asked Questions (FAQ)
• To review additional NIA resources, please visit the NIA Superior HealthPlan webpage.

To review the Medicaid prior authorization annual review report, please reference:

• 2021 Medicaid Prior Authorization Annual Review Report (PDF)
• 2021 Medicaid Prior Authorization Change Log (PDF)
• 2020 Medicaid Prior Authorization Annual Review Report (PDF)
• 2020 Medicaid Prior Authorization Change Log (PDF)

To review historical Medicare prior authorization lists, please reference:

• Medicare Prior Authorization List – Effective January 1, 2022 (PDF)
• Medicare Prior Authorization List – Effective July 1, 2022 (PDF)
• Medicare Prior Authorization List – Effective October 1, 2022 (PDF)

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/CHIP 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.

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 consistent with FDA recommendation for safe and effective use. Other medically necessary pharmacy services or products are covered consistent with VDP guidance.

• Prior authorization decisions for outpatient prescription benefits are finalized, and notification of the determination to the prescribing provider completed within twenty-four (24) hours of receipt of the request.
• Approval or denial of prior authorization requests received by phone will be finalized immediately, during the call.
• A 72 hour emergency supply of a drug will be dispensed to the patient for medications that require prior authorization in the following situations:
  • If the PBM cannot provide a response to the prior authorization request within 24 hours after receipt; OR
  • The prescriber is not available to make a prior authorization request because it is after the prescriber’s office hours and the dispensing pharmacist determines it is an emergency situation.

For a full listing of prior authorization requirements, please visit the following links:

• 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.
  

Physical Health Services, Supplies, Equipment, Behavioral Health Services, Clinician Administered Drugs, Orthodontia

Pharmacy Benefits

Approval or denial of prior authorization requests received by phone will be finalized immediately, during the call.

Orthodontia 

*Submit prior authorization requests for Orthodontic services for Medicaid (STAR, STAR Kids) and CHIP children to the appropriate Dental Maintenance Organization (DMO) contracted with Texas Health and Human Services (HHS).

• Concurrent utilization review to determine the medical necessity for inpatient days for a hospitalized patient is completed within one (1) business day of receipt.

• Prior authorization is required for all elective inpatient admissions.
• Prior authorization is NOT required for any urgent/emergent inpatient admissions that were not prior scheduled.
• Notification of non-elective inpatient admissions is required no later than the close of the next business day.
• Failure to notify within the timeframe required will result in a late notification denial, unless otherwise stated within a Superior contract.
• For notification of inpatient admission by service area throughout the state of Texas for all Medicaid and CHIP programs, please reference the phone and fax numbers below:

Physical Health Inpatient Admissions

• Concurrent utilization review to determine the medical necessity for inpatient days for a hospitalized patient is completed within one (1) business day of receipt.

Superior HealthPlan contracts with several licensed Utilization Review Agents (URAs) who have the clinical expertise to conduct utilization review for applicable services that are subject to authorization requirements.. These include the following Texas licensed Utilization Review Agents:

• Centene Company of Texas, LP (License #4167) – Physical Health, Behavioral Health and Clinician Administered Drugs
• Centene Management Company, LLC (License #5396) –  Physical Health, Behavioral Health and Clinician Administered Drugs
• Centene Pharmacy Solutions, Inc. (License #1774935) – Prescription Services
• DentaQuest USA Insurance Company, Inc. (License #1786622) – Orthodontic Services (STAR Health)
• Magellan Healthcare, Inc. (License #5197) – Medicaid Applied Behavioral Analysis Services
• Texas National Imaging Associates, Inc. (License #5258) – Radiology Services, Cardiac Imaging, and Physical, Occupational and Speech Therapy Services (STAR, CHIP, STAR+PLUS), Interventional Pain Management Services, Genetic Testing and Molecular Diagnostics
• Turningpoint Healthcare Solutions, LLC (License #2395464) – Musculoskeletal Surgical Procedures, Cardiac Surgeries, ENT Services (Nasal/Sinus Endoscopy, Tonsillectomy & Adenoidectomy, Tympanostomy, Myringotomy)