Prior Authorization Information

Prior Authorization Information

What is a prior authorization?

Community Health Choice members have access to all covered benefits that are medically necessary health care services. Some of these services need to be reviewed before the service is provided to make sure the service is appropriate and medically necessary. This review is called prior authorization, and is made by doctors, nurses and other health care professionals.

If a prior authorization request cannot be approved based on medical necessity, you will receive a letter with the reason why the prior authorization request was not approved. This is called a denial. You can ask Community Health Choice to review the denial again. This is called an appeal.

Questions?

Call 1.833.276.8306
(TTY users should call 711)

October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm.

On certain holidays your call will be handled by our automated phone system.

Please contact us if you have questions or need assistance:

Hours
Monday – Friday (excluding State-approved holidays),
8:00 a.m. to 6:00 p.m.

Phone

Local: 713.295.2294
Toll-Free: 1.833.276.8306

TDD Number for Hearing Impaired
7-1-1

Click here find a list of the covered services that require prior authorization. 

Healthcare providers are responsible for submitting prior authorization requests.  These can be submitted by phone, fax or online.  Your doctor can also get more information by visiting Community Health Choice’s Prior Authorizations webpage.

The timeframes for responding to prior authorization requests are listed below.

Physical Health Services, Supplies, Equipment, Behavioral Health Services, Clinician Administered Drugs (CAD)

Type of Request

Turnaround Time

Urgent

Within 1 business day from the receipt of a request

Routine

Within 3 business days from the receipt of a request

Inpatient

Within 1 business day from the receipt of a request

 

Pharmacy

Type of Request

Turnaround Time

Urgent, Routine

Within 24 hours from the receipt of a request

Community Health Choice will deny a claim if your provider does not obtain an authorization before providing services to you.  You will not be billed for payments for such services, unless services are not a benefit or as specified in your benefit plan.

Except for emergency services, post-stabilization services, and services provided to you during an approved inpatient admission, all services from an out-of-network provider must be prior authorized. Claims for services from out-of-network providers that are not approved before the service is given will be denied. You may receive a bill from the provider for those services.

H9826_IT_10045_092919_M Last updated January 12, 2021.

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“I always tell people to choose Community Health Choice. I tell them it’s the best health insurance they will ever be with.”

– Chandolyn
Member of Community Health Choice