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)
- Rendering Provider’s Name
- Rendering Provider’s NPI
- Rendering Provider’s Tax Identification Number
- 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 not enter the request in our system and will not approve or deny the request. 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)
- 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 that does not have complete or is missing supporting clinical documentation, El Paso Health will send a fax to the requesting provider no later than 3 Business Days after the prior authorization is received describing the specific list of what needs to be submitted and the date when it’s due.
If the information requested is not received by the end of the 3rd Business Day from the date El Paso Health sent the notice to the provider and the PA request will result in an Adverse Determination El Paso Health will send the request to the Medical Director for review with all information received with the PA request no later than the 7th Business Day after the PA receive date. The Medical Director may take up to 3 Business Days to complete the review and make a final determination. No later than the 10th Business Day from when the PA was received El Paso Health will make a final decision on the PA request.
A peer to peer consultation is available at any time during the PA process after an El Paso Health Medical Director review. El Paso Health will offer an opportunity for a peer to peer consultation to the requesting physician no less than one Business Day before an Adverse Determination is issued.