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.

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Monday – Friday (excluding State-approved holidays),
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Local: 713.295.2294
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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.

General Information
Local: 713.295.2222
Toll-Free: 1.877.635.6736

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

Member Services
Local: 713.295.2294 | Toll-Free: 1.888.760.2600
Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m.

Provider Services Hotline
Call 713.295.2295, 8:00 a.m. - 5:00 p.m., Monday – Friday

Additional Contact Numbers

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

For Spanish version, click here.

What is a prior authorization?

(Medicaid) 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, Community Health Choice will also verify if the Member has benefits.

Prior authorization is sometimes called pre-certification or pre-notification.

Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Community must still process a Provider’s claim to determine if payment will be made. The claim is processed according to:

  • Eligibility;
  • Contract limitations;
  • Benefit coverage guidelines;
  • Applicable State or Federal requirements;
  • National Correct Coding Initiative (NCCI) edits;
  • Texas Medicaid Provider Procedures Manual (TMPPM); and
  • Other program requirements, as applicable.