Skip to Main Content

Medicaid and CHIP Prior Authorization Requirements

Superior HealthPlan is responsible for ensuring the medical necessity and appropriateness of all health-care services for enrolled members. For some services, clinical review and prior authorization approval is required before the service is delivered.

A listing of the Medicaid and CHIP services that require prior authorization may be accessed by visiting:

In addition, an electronic tool is available on Superior’s website that provides procedure code specific information for the services, supplies, equipment and Clinician Administered Drugs (CAD) that require prior authorization. To view the Superior Prior Authorization Prescreen Tool, access the links below by program:

Medicaid and CHIP

For Ambetter, Medicare and STAR+PLUS MMP Prior Authorization Prescreen Tools, please visit:

Ambetter | Medicare Advantage | STAR+PLUS MMP.

Please reference the sections below for additional prior authorization requirements and information.

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 Notification Requirements for Inpatient Admissions 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. 

  • Fax, Phone, Web Contact Information
    • Prior authorization requests can be submitted by phone, fax or online through Superior HealthPlan’s Secure Provider Portal
    • Prior authorization phone assistance for providers is available on weekdays from 8am – 5pm in all time zones in Texas. Contact information for all services that require prior authorization are included below:
      • Prior Authorization Phone Numbers:
        • Physical Health: 1-800-218-7508
        • Behavioral Health: 1-844-744-5315
        • Clinician Administered Drugs (CAD): 1-800-218-7508, ext. 22080
        • Prescription Drugs: 1-866-399-0928
        • Radiology and Cardiac Imaging: 1-800-642-7554
        • Musculoskeletal Surgical Procedures: 1-855-336-4391
        • Orthodontics (STAR Health): 1-888-308-9345
      • Prior Authorization Fax Numbers:
        • Physical Health: 1-800-690-7030
        • Behavioral Health: 1-855-722-7079
        • Clinician Administered Drugs (CAD): 1-866-683-5631
        • Prescription Drugs: 1-866-399-0929
        • Radiology and Cardiac Imaging: 1-800-784-6864
        • Musculoskeletal Surgical Procedures: 1-833-409-5393
        • Orthodontics (STAR Health): 1-888-313-2883
      • Prior Authorization Secure Web Portals:
  • 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.
       
  • 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. 
       
  • Phone Requests
    • Prior authorization phone requests require subsequent submission of applicable documentation and clinical information to facilitate the medical necessity review of the request.
    • To access the prior authorization phone numbers for each applicable services type, please review the Prior Authorization Phone Contact List.
       
  • Fax Requests
    • Superior encourages providers to include a completed Authorization Request form with all prior authorization requests submitted through Fax.
    • For Authorization Request forms for applicable services, visit Superior’s Provider Forms webpage.
    • Applicable clinical documentation and information necessary to review the request must be submitted with all fax authorization requests.   
    • Prior authorization request fax numbers for each applicable service type are included under Prior Authorization Fax Numbers
       
  • Provider Identifiers
    • When submitting a request for 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.
       
  • Incomplete 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.
  • Medicaid Texas Health Steps Incomplete Information Process – Therapy, Home Health, DME
    • Applicable to prior authorization requests for Medicaid members under 21 years of age for Therapy, Home Health Services and Durable Medical Equipment (DME) Requests.
    • Superior will fax correspondence to the provider detailing the information necessary to complete the medical necessity review of the prior authorization request and providing the timeframe necessary for receipt of the requested information.
    • If the documentation/information is not provided with sixteen (16) business hours of Superior’s request:
      • Superior will mail a letter to the member explaining that the medical necessity review cannot be completed until is pending receipt of the requested information is received.
      • A copy of the letter will beis sent to the Medicaid provider describing the documentation/information requested and will be forwarded with the member communication.
    • If the requested information is not received within seven (7) calendar days of the letter to the member:
      • The prior authorization request will beis forwarded to Superior’s medical director for medical necessity determination, based on the clinical information available. This process will bise completed within fourteen (14) calendar days after receipt of the request from the provider.
  • Medicaid STAR Health (Foster Care) Pre-Appeal Process
    • The pre-appeals process is initiated for prior authorization requests when the available information does not meet the medical necessity criteria for the covered service.
    • The procedures for Pre-appeal include the following:
      • If the prior authorization request cannot be approved with the clinical information submitted with the request, the referring provider is contacted to conduct a 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 Team 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 entire Pre-Appeal process is completed within 14 calendar days of the authorization request.

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:

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

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 of Request

Prior Authorization Notification Timeframe 

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

Routine, Urgent/Expedited

24 hours

Orthodontia 

Program

Type of Request

Prior Authorization Notification Timeframe 

Medicaid (STAR Health)

Routine

3 business days

Medicaid (STAR Health)

Urgent/Expedited

24 hours

*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).

  • 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

Contact Phone Fax
Travis Service Area 1-800-218-7453 1-877-650-6939 
Nueces Service Area  1-800-656-4817 1-877-650-6940 
Dallas and Fort Worth Service Area 1-866-529-0294 1-855-707-5480 
El Paso Service Area Service Area 1-877-391-5923 1-877-650-6941
Lubbock and Amarillo Service Area 1-866-862-8308 1-866-865-4385
Hidalgo Service Area 1-866-862-8308 1-877-212-6661
Bexar Service Area 1-866-615-9399 1-877-650-6942 
Medicaid and CHIP Rural Service Area 1-866-615-9399 1-877-505-0823
Behavioral Health Inpatient Authorizations 1-844-842-2537 1-866-900-6918
  • 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 in tthe utilization review of for applicable prior authorization service requests. These include the following Texas licensed utilization review entities:

  • 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