Prior Authorization

El Paso Health may require authorization for certain services. Click on tool to help you determine if a prior authorization is required.

Prior authorization is based on information provided to El Paso Health at the time of request, it does not guarantee payment of benefits nor verify eligibility and is subject to all terms, conditions, limitations, and exclusions related to the member’s eligibility and subsequent medical review.

Regardless of prior authorization status, medical decisions concerning a course of treatment are solely between the physician and the patient.

Authorization requests are accepted via electronic through the El Paso Health Web Portal, fax, or telephonically.

Faxed Requests- use the Texas Standard Prior Authorization Request Form for Health Care Service, for behavioral services use the Behavioral Health Prior Authorization Form.

Electronic Requests (Web Portal):

Outpatient and/or Elective or Scheduled Procedures
Fax No: 915-298-7866
Toll Free: 844-2968-7866

Inpatient Notifications
Fax No: 915-298-5278
Toll Free: 844-298-5278

*The Fax Server is in operation twenty-four (24) hours a day, seven (7) days a week.

Telephonic Requests:
Ph. 915-532-3778 ext.1501
Toll Free: 877-532-3778 ext.1501

 Prior Authorization Annual Review Report

El Paso Health will use one or more of following proprietary or internally developed guidelines to determine whether to approve a prospective, concurrent, or retrospective review for medical necessity and appropriateness of the health care services:

• El Paso Health Clinical Guidelines for Therapy
• InterQual
• Milliman Care Guidelines (MCG)
• TMPPM (for information on limitations/restrictions click on link http://www.tmhp.com/resources/provider-manuals/tmppm)
• Texas Resiliency and Recovery Guidelines (for information on behavioral health services click on link https://hhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services-providers/behavioral-health-provider-resources/utilization-management-guidelines-manual

Required Information

To ensure El Paso Health has all it needs to initiate a prior authorization request you will need to submit the Texas Standard Prior Authorization Request Form for Health Care Services or for behavioral health the Behavioral Health Prior Authorization Form

The form must include the following essential information:

• Member name
• Member number
• Member date of birth
• Requesting Provider name
• Requesting Provider’s National Provider Identifier (NPI)
• Current Procedural Terminology (CPT)
• Healthcare Common Procedure Coding System (HCPCS)
• Service requested start and end dates
• Quantity of service units requested based on the CPT, or HCPCS requested

If El Paso Health receives a request for prior authorization with information that is incomplete, missing, incorrect, or illegible El Paso Health will return the request and provide an explanation by fax of why it is unable to be processed. You will need to resubmit the rejected prior authorization request with completed information.

The following supporting clinical documentation will be needed for El Paso Health to initiate and complete a review. Including, but not limited to:

• Completed Title XIX Form (For Medicaid only) for DME and Supplies
• Diagnostic/Lab tests relevant to the diagnoses;
• Member’s medical history relevant to the diagnoses;
• Member’s prognosis;
• Plan of treatment
• Physician order for requested service
• For Therapy (Occupational, Physical, or Speech therapy)
• Assessment
• Goals (long-term and short-term)
• ThSTeps or Physician clinical note
• Tests or other supporting information

If El Paso Health receives a request for a Medicaid member under the age of 21 years that does not have the complete supporting clinical documentation, El Paso Health will send a fax to the requesting provider describing what needs to be submitted and the date when it’s due.  If the information requested is not received within 16 hours of the request to the provider, El Paso health will send the member a letter letting them know that the request cannot be completed until the information requested is received.  El Paso Health will give the provider an additional seven (7) days from the date of the fax to submit the requested information.

El Paso Health will provide a determination of a review within the following timelines:

If you have questions or need help with the prior authorization process please don’t hesitate to call   El Paso Health Monday through Friday from 7:00 a.m. to 5:00 p.m. MST (excluding holidays) at the following number:

Members:
915-532-3778 or toll-free 1-877-532-3778 at extension:

• CHIP: 1516 (English), 1519 (Spanish)
• STAR: 1513 (English), 1518 (Spanish)

Providers:
915-532-3778 or toll-free 1-877-532-3778 at extension:

• CHIP: 1517
• STAR: 1514

PHARMACY PRIOR AUTHORIZATION PROCESS
Providers can submit Pharmacy Prior Authorizations (PA) for Outpatient Drugs to El Paso Health’s Pharmacy Provider Hotline at 1-877-908-6023.  Clinical staff is available 24 hours a day, 7 days a week.  Providers may also fax prior authorization forms to El Paso Health’s Pharmacy Prior Authorization at 1-855-668-8553.

Formulary

Formularies Available on Epocrates

Navitus

Pharmacy Quick Reference Guide

Preferred Drug List

For medication specific PA forms click here or submit the Texas Standard Prior Authorization Request Form for Prescription Drug Benefit.

PHARMACY PRIOR AUTHORIZATION TIMELINES: 

• El Paso Health will provide an immediate decision at the time of the call, when the caller is requesting a Medicaid prior authorization and has all the necessary information required to complete the prior authorization review. For all other requests, El Paso Health will notify the prescriber’s office of a prior authorization denial or approval no later than 24 hours after receipt.
• If El Paso Health cannot provide a response to the prior authorization request within 24 hours after receipt or the prescriber is not available to make a PA request because it is after the prescriber’s office hours and the dispensing pharmacist determines it is an emergency situation, El Paso Health will allow the pharmacy to dispense a 72-hour emergency supply of the drug. This requirement applies to drugs which can be filled as a 72-hour emergency supply.
• For CHIP prior authorization request, El Paso Health will provide a favorable determination when all information provided meets criteria for approval, no later than the second working day after the date of the request for utilization review and the receipt of all information necessary to complete the review.
• For CHIP prior authorization requests, when the information provided does not meet criteria, El Paso Health will issue a denial within three days. If El Paso Health questions the medical necessity or appropriateness, or the experimental or investigational nature of health care services prior to the issuance of a denial, the provider of record will be given a reasonable opportunity to discuss the plan of treatment for the member with a physician.
• If the information provided meets criteria for approval, El Paso Health will issue the favorable determination no later than the second working day after the date of the request for utilization review and the receipt of all information necessary to complete the review.