EPH has designed a tool to help you see if a pre-authorization is needed. It’s quick and easy. If an authorization is needed, make sure to log-in into the Provider Portal to submit your authorization.
Please note that failure to obtain authorization may result in administrative claim denials.
Check to see if a pre-authorization is necessary by using our online tool. Click here to get started.
REFERRALS NEEDED
As the medical home, PCPs should coordinate all health-care services for El Paso Health Members. PCPs are required to refer a member to a specialist when medically-necessary care is needed beyond the scope of the PCP. Referral to out-of-network providers will be made when medically-necessary to do so. All out-of-network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical records.
PRIOR AUTHORIZATIONS
Some services require prior authorization from El Paso Health in order for reimbursement to be issued to the provider. To view our product lists, use our Prior Authorization Prescreen Tool Medicaid/CHIP.
Standard prior authorization requests should be submitted for medical necessity review at least three (3) business days before the scheduled service delivery date, or as soon as the need for service is identified.
Authorization requests may be submitted by fax, phone or provider portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.
EMERGENCY ROOM AND POST STABILIZATION SERVICES DO NOT REQUIRE PRIOR AUTHORIZATION
Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admittance date.
El Paso Health will process most routine authorizations within three (3) business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to fourteen (14) calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, or provider portal.
El Paso Health hours of operation are Monday through Friday from 7:00 a.m. to 5:00 p.m., MST (excluding holidays).
