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
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.
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.
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.
Prior Authorization Annual Review Report
Report coming soon.
Prior Authorization Assistance
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.