GENERAL INFORMATION - PLEASE READ
Authorization is not a guarantee of payment. Claims payment is subject to Member Eligibility at the time of service and a properly completed claim form in accordance with applicable National Correct Coding Initiative (NCCI) edits, TMPPM requirements, and DHP claims completion requirements posted on our web site.
Member Eligibility: DHP encourages providers to verify eligibility of Medicaid members prior to each service. Eligibility verification is available on the DHP website or on the TMHP website.
In the event that a member is given retroactive eligibility by the Health and Human Services Commission (HHSC), DHP will allow a retroactive authorization for 30 days from the date retroactive eligibility is posted to the TMHP portal. Retroactive authorizations are subject to medical necessity review and all relevant utilization management criteria of DHP.
Timelines for completing prior authorization determinations: Click here
START of CARE: The Start of Care (SOC) date is the date that care is to begin as listed on the prior authorization request form. For further information and to view the Insufficient Lack of Information Start of Care Timeframe table, click here.
Submitting a Request for Authorization: Texas Standard Prior Authorization Request Form. Requests for Prior Authorization may be submitted through the DHP portal through our web site at www.driscollhealthplan.com (orange link above) or can be submitted by FAX to 1-866-741-5650 using the Texas Authorization Referral Form (TARF). Providers and members can search prior authorization criteria and requirements by selecting the yellow button above.
COB: Some outpatient services/procedure codes may require prior authorization regardless of DHP as secondary payer. Providers should verify authorization requirements utilizing the code look up tool found on this website. In cases where DHP is secondary payer and no prior authorization is required, providers should verify the services are a covered benefit by the primary payer.
Verifying Benefits: It is the Provider’s responsibility to verify the service(s)/procedure code(s) requested is a benefit of Texas Medicaid by utilizing the Texas Medicaid Provider Procedures Manual (TMPPM) and the Texas Medicaid Fee Schedule.
If the service requested is beyond the benefit limit or is not a covered benefit and the provider would still like to submit the request for consideration of medical necessity as a case-by-case benefit exception, the provider should fax the request to the DHP Utilization Management department at the number listed below with a statement on the fax coversheet indicating the requested service is a non-covered benefit or over the benefit limit.
Case by Case Benefit Exceptions: Requests for Case by Case services beyond the benefit limit or which are not a covered benefit may be considered with submission of supporting clinical documentation.
IMPORTANT PHONE NUMBERS FOR AUTHORIZATION REQUESTS AND INQUIRIES
To obtain assistance submitting a prior authorization request or to receive clarification on our prior authorization requirements, please contact us:
For Member assistance, please call:
DHP Member Services
Ph: 1-877-324-7543 toll-free
For Provider assistance, please call:
DHP Utilization Management
Ph: 1-877-455-1053
Fax: 1-866-741-5650
DHP STAR Kids LTSS Services
Ph: 1-844-376-5437
Fax: 1-844-381-5437
Hours of Operation:
Monday - Friday 8 a.m. - 5 p.m. (CST) (Except state holidays)
Messages will be returned within one business day.
Envolve Vision: 1-800-465-6972
https://www.envolvevision.com https://visionbenefits.envolvehealth.com/logon.aspx
Prescription Pharmacy ServicesNavitus: 1-877-908-6023
http://www.navitus.com/Texas-Medicaid-Star-Chip/Texas-Medicaid-Star-Chip-Main.aspx Navitus Prior Authorization Frequently Asked Questions
DHP Provider ServicesPh: 1-877-324-3627 toll-free
COORDINATION OF BENEFITS
Authorization and/or admission notification is required for inpatient services if DHP is secondary payer. No authorization is required for observation services if DHP issecondary payer. Some outpatient services/procedure codes may require prior authorization regardless of DHP as secondary payer. Providers should verify authorization requirements on the DHP Prior Authorization Portal at https://driscollhealthplan.com/priorauthcheck. In cases where DHP is secondary payer and no prior authorization is required, as based on directive within the DHP Prior Authorization Portal, providers should verify the services are a covered benefit by the primary payer. If the services are known to be a non-covered benefit by the primary payer, prior authorization is required by DHP and proof of non-coverage of benefit must accompany the claim submission. If this is the case, providers should submit prior authorization requests via fax and indicate on the cover page service is a non-covered benefit or over the benefit limit for primary payer.
SUBMISSION FOR PRIOR AUTHORIZATION - REQUIRED INFORMATION
CLINICAL INFORMATION AND DOCUMENTS REQUIRED WHEN SUBMITTING REQUESTS FOR PRIOR AUTHORIZATION
To avoid delays in processing of prior authorization requests and possible denials due to lack of supporting information, providers are encouraged to submit sufficient clinical information and documentation to validate the medical necessity for the services being requested. For a list of clinical information and documents that may be requested by Driscoll Health Plan to support medical necessity of requested services, click here. Only the applicable documents listed that are related to the requested services need be submitted.
INPATIENT ADMISSION AND DISCHARGE
Admission Notification and Prior Authorization request is required within one business day of admission unless otherwise noted below or on the Driscoll Health Plan Inpatient and Observation Admission Authorization Requirements document located at the Inpatient and Observation blue button below. Please reference this document for additional information. Prior Authorization requests will not be accepted after a claim has been submitted.
Admission Notification and Clinical Submission Timeframes:-
In Network Facilities:
- Admission notification: One business day.
- Clinical submission: Two business days from admission. If additional information is requested, one business day from date of request.
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Out of Network Facilities:
- Admission notification: Seven calendar days.
- Clinical Submission: As soon as possible, not to exceed seven calendar days from date of request.
Admission for delivery: No authorization or admission notification is required unless the stay needs to be extended beyond 4 days for a routine delivery or 6 days for a C-section delivery.
Pregnancy-related circumstances where actual delivery is not anticipated to occur (example: pre-term labor): Refer to Elective, Urgent or Emergent Acute Admissions protocols below.
NICU or Infant Continued Admissions after Discharge of Mother: No admission notification or prior authorization is required for Newborn Nursery and NICU Level II admissions unless the length of stay is extended beyond 5 days. Admission notification within one business day of admission is required for NICU Level III and Level IV, regardless of length of stay. Hospitals must follow DHP’s transfer protocols for infants born less than 29 weeks gestation or less than 1,000 grams.
Elective Acute or Mental Health/Substance Use Disorder Admissions and Observations (excluding OB Observations): Prior Authorization is required.
Urgent or Emergent Acute or Mental Health/Substance Use Disorder Admissions and Observations: Admission notification within one business day of admission.
Discharge Planning: Hospitals must provide DHP with notification of pending discharge as early as practical. This allows DHP case managers to work with the hospital case managers and ensure the patient/member has everything needed to make a successful transition to home.
CLINICAL CRITERIA
InterQual: Driscoll Health Plan utilizes proprietary InterQual review criteria in the process of managing utilization for prospective, concurrent and retrospective review.
Driscoll Clinical Guidelines: Driscoll Health Plan peer reviewers utilize proprietary as well as internally developed criteria and evidence based guidelines, such as The American College of Obstetrics and Gynecology (ACOG), The American Academy of Pediatrics (AAP), The American Medical Association (AMA), Texas Health and Human Services Commission (HHSC) and Driscoll Health Plan policy.
Driscoll Clinical Guidelines for LTSS Services: Driscoll Health Plan bases determinations for STAR Kids Support Services utilizing criteria developed by the Texas Department of Aging and Disability Services (DADS), Medically Dependent Children Program (MDCP), Health and Human Services Commission (HHSC) guidelines, and DHP internal guidelines for LTSS services requested. For LTSS Services, the STAR Kids Screening and Assessment Instrument (SAI) performed by the Service Coordinator will determine medical necessity for the LTSS services.
TMPPM: DHP utilizes the same clinical guidelines for many services as found in the current Texas Medicaid Provider Procedures Manual.
For more information, click on an applicable category of service below:
OUT-OF-NETWORK PROVIDERS
An authorization is required for all services performed by a non-participating provider with the following exceptions:
Texas Health Step (aka EPSDT exams) Well-child Exams (99381-99385 or 99391-99395)
Family Planning Services for STAR or STAR Kids members
Primary care services in a Federally Qualified Health Center (FQHC)
Routine in-hospital deliveries
Outpatient mental health or substance services, except for Psychological Testing Services
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