Prior Authorization

Prior Authorizations

Prior Authorization Help, Forms & Contact Information

An authorization is required for all inpatient admissions, outpatient procedures, out-of-area and out-of-network services, and other services as defined by El Paso Health, except for family planning services.

For a full list of procedures requiring authorization,
View the Pre-Authorization Flyer.

All necessary forms are available on our
Provider Forms Page.

Our Utilization Management staff is readily available to assist providers with prior authorization questions, including pharmacy-related requests.

  • Phone: 915-532-3778
  • Toll-Free: 1-877-532-3778
  • Hours of Operation: Monday through Friday, 8:00 a.m. to 5:00 p.m. MT (excluding state holidays)

Prior Authorization Catalog & CPT Search Tool


Services Requiring Prior Auth


Prior Auth Requirements Catalog


Submitting a Prior Authorization Request

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 by telephone.

Outpatient and/or Elective or Scheduled Procedures

Fax No: 915-298-7866  |  Toll Free: 844-298-7866

Inpatient Notifications

Fax No: 915-298-5278  |  Toll Free: 844-200-5278

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

Telephone Request

STAR: 915-532-3778  |  877-532-3778 (Toll Free)

STAR+PLUS: 833-742-3127 (Toll Free)

Determination Timelines

Request Type Determination Timeframe
Standard/Routine Within three (3) business days after receipt of the request
Expedited/Urgent Within one (1) business day after receipt of the request
Inpatient Within one (1) business day after receipt of the request
Post-Stabilization Within one (1) hour of receipt of request, if the request is related to post-hospitalization or life-threatening conditions, except that for Emergency Medical Conditions and Emergency Behavioral Health Conditions, EPH will not require prior authorization.

Exceptions

  • Vision services need to be verified by Envolve Vision Services.
  • Dental services need to be verified by DentaQuest/MCNA.
  • Medicaid Members: Family Planning services with a contraceptive management diagnosis do not require an authorization whether the Provider is In-Network or Out-of-Network.
  • CHIP Members: Family Planning services with a contraceptive management diagnosis are not a benefit.
  • THSteps checkups do not require an authorization whether Provider is In-Network or Out of Network.

Pharmacy Prior Authorizations & Resources

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 1-855-668-8553.

Pharmacy PA Timelines

  • Immediate decision at the time of the call for Medicaid PA when all information is available. For all other requests, El Paso Health notifies the prescriber of approval/denial within 24 hours after receipt.
  • If a response cannot be provided within 24 hours after receipt, or if it is after prescriber office hours and the dispensing pharmacist determines an emergency, El Paso Health allows a 72-hour emergency supply when applicable.
  • For CHIP requests meeting approval criteria, a favorable determination is provided no later than the second working day after the date of the request and receipt of all necessary information.
  • For CHIP requests that do not meet criteria, a denial is issued within three days. If medical necessity/appropriateness is questioned prior to denial, the provider of record is given a reasonable opportunity to discuss the plan of treatment with a physician.

Medication-Specific Forms

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

Pharmacy Resources

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.

Essential Information

  • Member name; number; date of birth
  • Requesting Provider name and NPI
  • Rendering Provider name, NPI, and Tax ID
  • Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System (HCPCS)
  • Service requested start and end dates
  • Quantity of service units requested based on CPT/HCPCS

If a request is incomplete, missing, incorrect, or illegible, El Paso Health will not enter the request and will return it with an explanation by fax. Please resubmit with the completed information.

Annual Review & Change Log

Provider & Member Assistance

Providers

Phone (Local): 915-532-3778  |  Toll-Free: 1-877-532-3778

Extensions: CHIP: 1517  |  STAR: 1514

Hours: Monday–Friday, 8:00 a.m.–5:00 p.m. MT (excluding state holidays)

Members

STAR/CHIP Members: 915-532-3778 (Local)  |  1-877-532-3778 (Toll-Free)

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

STAR+PLUS Members/Providers: 1-833-742-3127 (Toll-Free)

Hours: Monday–Friday, 8:00 a.m.–5:00 p.m. MT (excluding state holidays)

Disclaimer

All attempts are made to provide the most current information on the Prior Authorization Search Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

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