El Paso Health may require authorization for certain services. We have designed a tool to help you determine if a prior authorization is required.
If an authorization is needed, make sure to log-in into the Provider Portal to submit your authorization.
|Outpatient Utilization||Inpatient Utilization|
|Fax: 915-298-7866||Fax: 915-298-5278|
|Toll Free Fax: 1-844-298-7866||Toll Free Fax: 1-844-298-5278|
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.
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. 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.
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 the Texas Standard Prior Authorization Request Form for Health Care Service or similar prior authorization form. Urgent requests for prior authorization should be called in as soon as the need is identified.
We will process standard 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. El Paso Health will send the provider and member a notice informing them of the specific documentation required to complete the prior authorization such as, but not limited to, diagnostics, plan of care, Title XIX, and the date the additional information is due. Authorization determinations may be communicated to the provider by fax, phone, or provider portal.
For expedited requests in which a Provider indicates that a standard timeframe could seriously jeopardize the Member’s health, we will make an authorization decision and provide notice as expeditiously as the enrollee’s health condition requires within 1 business day but no later than 72 hours after receipt of the request for service.
Prior authorization requirements were reviewed and effective October 1, 2019.
To clarify or obtain assistance with prior authorization requirements you may contact us at 915-532-3778 or toll-free at 1-877-532-3778, Monday through Friday from 7:00 a.m. to 5:00 p.m., MST (excluding holidays).
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.