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 Prior Authorization List Effective 01/01/2021
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.
Prior authorization is sometimes called pre-certification or pre-notification. Prior authorization verifies whether medical treatment that is not an emergency is medically necessary. It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Baylor will also verify if the Member has benefits.
Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Baylor must still process a Providers claim to determine if payment will be made. The claim is processed according to:
- Contract limitations
- Benefit coverage guidelines
- Applicable State or Federal requirements
- National Correct Coding Initiative (NCCI) edits
- Texas Medicaid Provider Procedures Manual (TMPPM)
- Other program requirements, as applicable
Prior Authorization Requests: Essential Information & Supporting Clinical Documentation
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information to initiate the prior authorization review process:
- Member name
- Member date of birth
- Member number
- Requesting provider name
- Requesting providers National Provider Identifier (NPI)
- Rendering providers name
- Service requested:
- Current Procedural Terminology (CPT)
- Healthcare Common Procedure Coding System (HCPCS)
- Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
- Requesting Providers Dated Signature
Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted. To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.
Supporting Clinical Documentation
Lack of Information
When RightCare receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
- RightCare will notify the Member by letter that an authorization request was received but cannot be acted upon until RightCare receives the missing documentation/information from the requesting Provider. The letter will include the following information:
- A statement that RightCare has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- Timeline for the provider to submit the missing information.
- Contact information and modes of communication for provider inquiry if necessary.
- RightCare will contact Provider via fax or phone and request documentation for completion of the medical necessity review within three business days of RightCare receipt of request (where applicable).
- If RightCare does not receive the documentation/information by the end of the third business day of our request to the requesting Provider, the request will be submitted to the Medical Director no later than the seventh business day after receipt of request (where applicable).
- RightCare will render a decision no later than the tenth business day after the request received date.
Essential Information to Initiate an Authorization
If you submit a prior authorization request that includes all Essential Information, we will process the request following our established timelines and guidelines. If Essential Information is missing, incorrect, or illegible, we will be unable to make a decision. We will return all requests that are missing Essential Information to you with an explanation of why it was not processed and instructions for resubmission.
A prior authorization request must include the following Essential Information:
Member number or Medicaid number
Member date of birth
Requesting provider name
Requesting provider’s National Provider Identifier (NPI) or Atypical Provider Identifier (API)
Rendering provider’s name
Rendering provider’s National Provider Identifier (NPI) or Atypical Provider Identifier (API)
Rendering provider’s Tax Identification Number (TIN)
Service requested start and end dates
Service requested–Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT) codes
Quantity of service units request based on the CPT, HCPCS, or CDT codes requested
Complete Authorization Requests
As a reminder, authorization requests must include all information and documentation that is required to make a medical or functional necessity determination. Submit all required information and documentation for your prior authorization request through our portal, by fax, or by calling us at 1-855-691-7947.
In addition, requests for outpatient prior authorization submitted through our portal require that clinical information be added prior to submission. To be considered a complete request, the following clinical information from the past 12 months (but not limited to) must be submitted:
Rationale for out-of-network services
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
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, behavioral health authorizations require:
Level of functioning, including an ability to perform activities of daily living
Presence of suicidal or homicidal ideations
Mental status assessment
Participation in the milieu
Incomplete or Insufficient Documentation
The following process applies when we receive incomplete prior authorization requests that are missing Essential Information for Medicaid members:
- We will notify the requesting provider of missing information no later than 3 business days after receipt of a prior authorization request submitted through our portal, by phone, or by fax. The provider will have 3 business days to provide the missing information. Business day is defined as a day other than Saturday, Sunday, or state or federal holiday on which Texas Health and Human Services Commission’s offices are closed.
- We will notify the member of the missing information no later than 3 business days after receipt of a prior authorization request through U.S. mail or other preferred method of notification.
- We will refer the request to the medical director no later than 7 business days after receipt of the prior authorization request, if we do not receive the information requested and the available information does not meet medical necessity guidelines.
- We will make a determination within 3 business days of the referral for medical director review, but no later than the 10th business day after receipt of the request.
- We will offer an opportunity for the medical director to consult with the requesting provider no less than 1 business day before issuing an adverse determination.
- We will mail the requesting provider and the member written final determination no later than the next business day after the determination is decided.
Final determinations will be made within 3 business days after the date that missing information is provided to us. If a holiday (e.g., Christmas) will result in the process exceeding the 14-day time limit, we will adjust the timeline accordingly, so that the process does not exceed 14 days.
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
PA Change Log (2020)
PA Annual Review 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 1-855-395-9652 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.
To obtain prior authorization assistance for members, please call 1-855-TX-RIGHT (1-855-897-4448) 7 a.m. to 7 p.m. Central Time, Monday to Friday (except for state-approved holidays) TTY: 711.
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.
A 72-hour emergency supply of a prescribed drug may be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring a prior authorization (PA), either because they are non-preferred drugs on the Preferred Drug List or because they are subject to clinical edits.
The 72-hour emergency supply may be dispensed when a PA cannot be resolved within 24 hours for a medication on the Vendor Drug Program formulary that is appropriate for the member's medical condition. If the prescribing provider cannot be reached or is unable to request a PA, the pharmacy should submit an emergency 72-hour prescription. The emergency supply is subject to pharmacist clinical judgement. Some non-urgent medications are exempt from this emergency supply.
A pharmacy can dispense a product that is packaged in a dosage form that is fixed and unbreakable, e.g., an albuterol inhaler, as a 72-hour emergency supply.
To be reimbursed for a 72-hour emergency prescription supply, pharmacies should submit the following information:
Claim Submission Process:
Place '8' in "Prior Authorization Type Code" (Field 461-EU), '801' in "Prior Authorization Number Submitted" (Field 462-EV) and '3' in "Days' Supply" in the claim segment of the billing transaction (Field 405-D5).
The quantity submitted in "Quantity Dispensed" (Field 442-E7) should not exceed the quantity necessary for a three-day supply. It is permissible that a pharmacy dispense product packages in fixed dosage forms (e.g., inhalers, nebulized medications) that are unbreakable as a 72-hour supply. Place '3' in "Days' Supply" but enter the full quantity dispensed.
Call Navitus at 1-877-908-6023 or RightCare at 1-855-897-4448 for more information about the 72-hour emergency prescription supply policy.