About Notifications and Prior Authorizations
Some services require notifications or prior authorization. All out-of-network physician, hospital, or ancillary service requests require prior authorization.
Notification and Prior Authorization Lists
Medical and Behavioral Services
Medical Services Prior Authorization List Effective 01/01/2020
RightCare Authorization Request Form & Instructions
Behavioral Health Referral Authorization Form and Instructions
Medical Coverage Policies
Medical Policy and Prior Authorization Update Notices
Prior Authorization Process
Certain services require authorization in order to be covered by RightCare. Authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment—including prescribed drug intervention—relative to approved evidence-based medical criteria. Authorization is required to ensure that a requested medical service is medically necessary and that the member will receive the benefits to which they are entitled. Prior authorization requests must be received before the services are provided to the member. Failure of a provider to contact RightCare for the required prior authorization of services and/or rendered prior to notifying RightCare will relieve both RightCare and the member from any financial responsibility for the service(s) in question.
Providers are advised to leave their fax systems on at all times in order to receive correspondence from RightCare (i.e. requests for additional clinical, options for peer-to-peer review, etc.) during and after business hours.
Essential Information to Initiate an Authorization
If the PA request has Essential Information, the PA request will be processed. If Essential Information on a PA request is missing, incorrect, or illegible, a decision to approve or deny cannot be made. We will return the request to the requesting provider with an explanation of why the submitted request was not processed as submitted and include instruction to resubmit the PA request with complete Essential Information. A complete request form includes the following Essential Information:Member Name Member Number Member Date of Birth Ordering Provider Service Provider Name National Provider Identifier (NPI) Tax Identification Number (TIN) Date of Service Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS)Quantity of service units requested based on the CPT, HCPCS, or CDT requested.
Complete Authorization Requests
An authorization request must include all information/documents required to make and establish a medical or functional necessity determination. Utilization Management staff receive current clinical via fax, phone, or confidential voice mail from the requesting provider, attending physician, facility personnel or access to a facility-specific electronic medical record. In addition, online requests for outpatient prior authorization require clinical information attachment prior to submission. In order to apply the appropriate medical policy and make a decision, the following clinical information from the past 12 months (but not limited to) must be submitted: Office and hospital records A history of the presenting problem A history of previous medical management Physical exam results Diagnostic testing results Treatment plans and progress notes and prognosis Patient psychosocial history Information on consultations with the treating practitioner Evaluations from other health care practitioners and providers Operative and pathological reports Rehabilitation evaluations Patient characteristics and information Information from responsible family members or caregivers Community resources for discharge planning and follow up care Any other information deemed necessary to facilitate the decision-making process.
In addition to the above, the following information is collected specific to behavioral health authorizations: Level of functioning, including an ability to perform activities of daily living Presence of suicidal or homicidal ideations Mental status assessment; and Participation in the milieu.
Incomplete or Insufficient Documentation
The following process applies when the RightCare receives a request for prior authorization for a member under age 21, and the request does not contain complete documentation and/or information:
- RightCare returns the request to the Medicaid provider with a letter describing the documentation that needs to be submitted, and when possible, RightCare will contact the Medicaid provider by telephone and obtain the information necessary to complete the prior authorization process.
- If the clinical information is not provided within sixteen (16) business hours of RightCare’s request to the Medicaid provider, RightCare sends a letter to the member explaining that the request cannot be acted upon until the documentation/information is provided, along with a copy of the letter sent to the Medicaid provider describing the clinical information that needs to be submitted.
- If the clinical information is not provided to RightCare within seven calendar days (7) of its letter to the member, RightCare sends a notice to the member informing the member of its denial of the requested service due to the incomplete documentation/information, and providing the member an opportunity to request an appeal through RightCare’s internal appeals process and the HHSC fair hearing process.
Prior Authorization Timeline
- Within three Business Days after receipt of the request for authorization services;
- Within one Business Day for concurrent Hospitalization decisions; and
- Within one hour for post-hospitalization or life-threatening conditions, except that for Emergency Medical Conditions and Emergency Behavioral Health Conditions, prior authorization is not required.
Prior Authorization Annual Review Report Annual Review Report (2020)Prior Authorization Report (10_2020)
Prior Authorization Assistance
To obtain a prior authorization assistance, RightCare in-network providers are encouraged to log in to the RightCare Provider Self-Service portal to verify eligibility status and utilize the Authorization Code Look-up to submit new authorization requests, view authorization status, and view prior authorization requirements. Alternately, complete the Essential Information to Initiate an Authorization on the RightCare Authorization Request Form and submit the Complete Authorization Request to via fax. Appropriate personnel are available to respond to utilization review inquiries 8:00 a.m. to 5:00 p.m., Monday through Friday, with a telephone system capable of accepting utilization review inquiries outside of these hours. Please call toll-free at 1-855-691-7947 for medical prior authorization and 855-395-9652 for behavioral prior authorization.
To obtain a pharmacy prior authorization assistance, please call RightCare’s PBM, Navitus, Toll Free at 1-877-908-6023, and select the prescriber option to speak with the Prior Authorization department between 6 a.m. to 6 p.m. Monday through Friday, and 8 a.m. to 12 p.m. Saturday and Sunday Central Time (CT), excluding state approved holidays.
Pharmacy Notifications and Prior Authorizations
RightCare is state mandated to adhere to the Texas Medicaid formulary and Preferred Drug List, which are developed and maintained by the Texas Drug Utilization Review (DUR) Board and Texas HHSC Vendor Drug Program (VDP). Additional information regarding VDP including formularies, preferred drug list, and Texas DUR Board meeting minutes and updates can be found on the Texas Vendor Drug Program webpage.
RightCare administers the prior authorization criteria approved by the Texas DUR Board. For a listing of clinical edits implemented by RightCare please click here, and for access to RightCare’s prior authorization forms please click here.
Pharmacy Prior Authorization Timeline
- If the prescriber’s office calls the MCO’s PA call center, the MCO must provide prior authorization approval or denial immediately.
- For all other PA requests, the MCO must notify the prescriber’s office of a PA denial or approval no later than 24 hours after receipt.
- If the MCO cannot provide a response to the PA 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, the MCO must allow the pharmacy to dispense a 72-hour supply of the drug.