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.

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.

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.

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.

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.

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.

Vision Services
Envolve Vision: 1-800-465-6972

https://www.envolvevision.com
https://visionbenefits.envolvehealth.com/logon.aspx

Prescription Pharmacy Services
Navitus: 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 Services
Ph: 1-877-324-3627 toll-free

SUBMISSION FOR PRIOR AUTHORIZATION

Timelines for completing prior authorization determinations: Click here


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. A list of clinical information and documents that may be requests by Driscoll Health Plan to support medical necessity of requested services can be found on this website. Only the applicable documents listed that are related to the requested services need be submitted.

Clinical Information and Documents to Support Medical Necessity 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.

Outpatient Services

DHP Member Coverage Unknown Retro-Enrollment and assignment to DHP
Where prior authorization was required and DHP coverage is identified after services are rendered, authorization is required prior to claims submission. DHP will conduct retrospective review of medical necessity for the services rendered without penalty for late notification if the reason provided is substantiated in the request for authorization. Where prior authorization was required and retro assignment to DHP is identified after services are rendered, authorization is required within 30 days of the retro assignment date and prior to claims submission. DHP will conduct retrospective review of medical necessity for the services rendered without penalty for late notification if indication of retro-assignment as reason for late notification is provided and substantiated in the request for authorization.

Inpatient Services

DHP Member Coverage Unknown Retro-Enrollment and assignment to DHP
If DHP coverage was unknown upon admission, and identified during the stay, authorization is required. DHP will process the authorization request without penalty for late notification if the reason for late notification provided is substantiated in the request for authorization. If retro-assignment to DHP is identified during the stay, authorization is required within 30 days of the retro-assignment date. DHP will process the authorization request without penalty for late notification during this timeframe. Indication of retro-assignment as reason for late notification must be provided with the authorization request.
If DHP coverage identified post discharge but prior to claim submission, authorization is required prior to claims submission. DHP will conduct retrospective review of the stay without penalty for late notification if the reason for late notification provided is substantiated in the request for authorization. If retro assignment to DHP is identified after discharge and prior to claim submission, authorization is required within 30 days of the retro-assignment date and prior to claims submission. DHP will conduct retrospective review of the stay without penalty for late notification. Indication of retro-assignment as reason for late notification must be provided with the authorization request.

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.

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.
  • 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


Enter Code To Check:

Page 1 of 7 (65 items)Prev1234567Next
FILTER CODE: 
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10040


AUTHORIZATION REQUIRED

PR ACNE SURGERY OF SKIN ABSCESS CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10060


AUTHORIZATION REQUIRED

PR DRAIN SKIN ABSCESS SIMPLE CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10061


AUTHORIZATION REQUIRED

PR DRAIN SKIN ABSCESS COMPLIC CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10080


AUTHORIZATION REQUIRED

PR DRAIN PILONIDAL CYST SIMPL CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10081


AUTHORIZATION REQUIRED

PR DRAIN PILONIDAL CYST COMPLIC CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10140


AUTHORIZATION REQUIRED

PR DRAINAGE OF HEMATOMA/FLUID CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10160


AUTHORIZATION REQUIRED

PR PUNCTURE DRAINAGE OF LESION CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

10180


AUTHORIZATION REQUIRED

PR COMPLEX DRAINAGE, WOUND CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

26010


AUTHORIZATION REQUIRED

PR DRAIN FINGER ABSCESS,SIMPLE CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
HCPCS/CPT4 CODES DESCRIPTION COVERED BENEFITS NON COVERED BENEFITS PRIOR AUTHORIZATION EFFECTIVE DATE

26011


AUTHORIZATION REQUIRED

PR DRAIN FINGER ABSCESS,COMPLICATED CHIP, STAR, STAR KIDS CHIP PERINATE 5/10/2021
ALERTS AND LIMITATIONS REVIEW CRITERIA DOCUMENTATION REQUIREMENT CRITERIA REVIEW DATE
PLACE OF SERVICE: PRIOR AUTH IS REQUIRED IF PERFORMED IN OUTPATIENT SETTING (22, 24)., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY REFER TO TMPPM
Page 1 of 7 (65 items)Prev1234567Next