Authorization Information

• FirstCare Medicaid - CHIP Wheeled Mobility Form
• Texas Standard Prior Authorization Request Form for Health Care Services
• HHSC Prescribed Pediatric Extended Care Center (PPECC) Plan of Care
• HHSC Nursing Addendum to Plan of Care for PPECC

• FirstCare Prior Authorization Request Form
• Behavioral Health Toolkit

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 under their plan.

This page outlines information regarding prior authorization for services or medications obtained under the Medical benefit. For information regarding prior authorization for medications obtained under the pharmacy benefit, refer to the “Pharmacy Information” section.

Failure of a network provider to contact FirstCare for the required prior authorization of services covered under the member’s plan and/or rendered prior to notifying FirstCare will relieve both FirstCare and the member from any financial responsibility for the service(s) in question.

To obtain medical prior authorization assistance, FirstCare utilization management staff are available to receive authorization requests and to answer questions about authorization requirements or processes at 1-800-884-4905 (6 a.m. to 6 p.m. CT weekdays and 9 a.m. to noon CT weekends and holidays). Requests may be submitted 24/7 online after logging in to the FirstCare Provider Self-Service portal. Requests may also be submitted via fax at 1-800-248-1852, 24 hours a day, 365 days a year.

To obtain medical prior authorization assistance for members:

Call 1-800-431-7798, from 7 a.m. to 7 p.m. Central Time (CT) weekdays.

Affirmative Statement About Incentives

• All services, even if authorized, are subject to the member’s benefit plan contract coverage and exclusions, eligibility and network design. Approvals are not a guarantee of coverage, as the member’s benefit plan contract may retroactively terminate at a future date. Benefit plan contract exclusions and current status of eligibility may be verified by logging into the FirstCare Provider Self-Service portal. Out-of-network providers are encouraged to contact FirstCare’s Customer Service with any questions regarding benefit limitations.
• All transplant services require prior authorization.
• Cosmetic procedures are not covered for most plans. Please refer to the member's plan documents—Evidence of Coverage (EOC) or Certificate of Insurance (COI)—for further details as some reconstructive procedures may be covered if medical necessity criteria are met.

• Home Health Requirements

  • Prior authorization is required for home health services. Services may include home health aide, occupational therapy, physical therapy, skilled nursing, speech therapy and/or social work. Prior authorization is not required for physical or occupational therapy evaluation.
  • The first visit for newly ordered home Skilled Nursing and home Speech Therapy requires authorization but will not require a prior authorization. FirstCare will retrospectively approve the initial nursing evaluation visit and/or speech therapy evaluation when the written evaluation and plan of care is received—within four (4) business days. Any additional services rendered during those four business days will also be retrospectively reviewed.

• Inpatient Authorization Requirements

  • Services or codes listed within this document require prior authorization and will have a separate authorization number.
  • For acute levels of inpatient care, FirstCare requires notification within 24 hours (or next business day for holiday weekends).
  • If, in the judgment of the rendering provider, the care is of an emergency or urgent nature, medical necessity review is required after the care begins.
  • Notification is required for obstetrical (OB) delivery when an associated inpatient stay is expected to exceed 48 hours post vaginal delivery or 96 hours post-cesarean delivery.
  • Prior authorization on/before services are rendered is required for Inpatient Rehabilitation, Skilled Nursing Facility (SNF), Long term Acute Care (LTAC).

• Out-of-Network Provider/Facility Services

  • Referrals to out-of-network providers must be pre-authorized and may be covered by FirstCare when one or more of the following conditions are present:
    • Life threatening emergency situation exists and delivery of services is appropriate or timely;
    • Access to an in-network facility or service is not reasonably practical or possible;
    • Medically necessary, covered medical service is not available through an in-network Provider;
    • Service or care is available in-network, but not accessible; and/or
    • Service is available in-network, but there is a continuity of care concern for a new member (e.g. any high risk pregnancy in the second trimester, a pregnancy in the third trimester or any other situation which, in the judgment of the Medical Director warrants an out-of-network authorization to complete a particularly complex episode of care).
  • Exceptions: Emergency Services. Rendering Medicaid providers must have a TPI.
• Failure to obtain prior authorization for out-of-network services may result in a denial of payment for services rendered. Out-of-network providers should submit prior authorization requests by completing and faxing the FirstCare Prior Authorization Request Form.
• All services that are considered experimental/investigational or potentially cosmetic require prior authorization.
• Providers may contact FirstCare Health Plans to request a copy of the actual benefit provision, guideline or other criteria on which a determination was made. For details on reaching out to FirstCare, please click here.

Providers are advised to leave their fax systems on at all times in order to receive correspondence from FirstCare (i.e. requests for additional clinical, options for peer-to-peer review, etc.) during and after business hours.

• Member name
• 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

• 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
• Rehabilitation evaluations
• 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

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.

• 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.

• 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.

• Each list includes statistics on:
  • Prior authorizations approved
  • Prior authorizations denied
  • Adverse determinations overturned on internal appeal
  • Total number of prior authorizations

• FirstCare Diagnosis Label & Code (2018)
• FirstCare Service Type & Specialty (2018)
• STAR & CHIP Prior Authorization Annual Review Report (2020)
  Prior Authorization Report (10_2020)