Prior Authorization

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Prior authorization is the review of the medical necessity and appropriateness of selected physical health and behavioral health services before they are provided.

If faxing prior authorization requests for more than one member, each member request must be faxed individually. Requests received with multiple members will be returned for resubmission to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance.

Essential Information is defined by the Uniform Managed Care Manual 3.22 as the information required to initiate the prior authorization (PA) review process:

  • Member name
  • Member number or Medicaid number
  • Member date of birth
  • Requesting provider name
  • Requesting provider’s National Provider Identifier (NPI)
  • Service requested: Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS)
  • Service requested start and end date(s)
  • Quantity of service units requested based on the CPT or HCPCS requested

Parkland Community Health Plan also requires the following information to initiate and process a prior authorization.

  • Rendering provider’s name
  • Rendering provider’s National Provider Identifier (NPI)
  • Rendering provider’s Tax Identification Number

If a prior authorization request is missing documentation to determine medical necessity and it will likely result in an adverse benefit determination, the prior authorization request must be limited to the prior authorization requirements listed on PCHP’s website on the date the request is received.

Review of the prior authorization criteria is completed annually.

When requesting authorizations:

Submitting a request

A request for prior authorization is not a guarantee of payment. Unauthorized services will not be reimbursed. You can submit a request to:

  • Prior Authorization Request:
    • Fax Number: 214-266-2085
    • Toll-Free Fax: 1-844-303-1382
  • Inpatient Prior Authorization Requests:
    • Fax Number: 214-266-2084
    • Toll-Free Fax: 1-844-303-2807
  • Behavioral Health Prior Authorization Requests:
    • Fax Number: 214-266-2064
    • Toll-Free Fax: 1-844-266-2064

To request an authorization, find out what services require authorization, or check on the status of an authorization, visit PCHP's secure Provider portal. 

For more information about prior authorization, review your Provider manual. 

Need help with authorizations, denials or something else? Call our Provider Services at 1-888-672-2277. 
Hours of operation are 8 am - 5 pm CST, Monday - Friday (except state holidays).

Prior Authorization Timelines

Prior authorization timelines include: 

Nonurgent pre-service: For prior authorization of nonurgent care, a decision will be made within 3 business days from the date of request. 

Urgent/expedited pre-service: For prior authorization of urgent/expedited pre-service care, a decision will be made as expeditiously as a member’s condition requires and no later than 72 hours after receipt of the request. 

Urgent concurrent: For urgent concurrent care, a decision will be made within 1 business day – not to exceed 72 hours of receipt of the request for service or notification of inpatient admission. 

Post-service: For post-service care, a decision and notification are required within a reasonable period but no later than 30 calendar days from the receipt of the request. 

Post-stabilization: For post-stabilization, a decision will be made within 1 hour for post-stabilization or life-threatening conditions, except for emergency medical conditions and emergency behavioral health conditions where prior authorization is not required. 

For a member who is hospitalized at the time of the request, a decision is required within 1 business day of receiving the request for services or equipment that will be necessary for the care of the member immediately after discharge, including if the request is submitted by an out-of-network provider, a provider of acute care inpatient services, or a member. 

If there is no response to a prior authorization request within 24 hours, a 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization is not available. 

Incomplete Prior Authorization Requests

An incomplete prior authorization request is a request for a service that is missing information needed to decide medical necessity. Parkland Community Health Plan will notify the requesting provider and member, in writing, of missing information no later than 3 business days after receiving the prior authorization request. 

If any of the information is missing, illegible or incomplete, Parkland Community Health Plan will contact the provider or member by phone or in writing to obtain the information necessary to resolve the incomplete prior authorization request. 

The Start of Care (SOC) date is the date that care is to begin as listed on the prior authorization request form. Exceptions to this SOC date may include prior authorization requests for home health skilled nursing, aide services, private duty nursing (PDN), physical therapy, occupational therapy, and speech therapy services. PCHP must honor the SOC date if the provider responds to us timely and is able to submit additional information sufficient to classify a request as complete within the timeline detailed in Section V of HHSC UMCM Chapter 3.22, and PCHP has determined that the requested services meet medical necessity from the SOC date. 

If the information requested is not received within 3 business days from the date that the plan sent the notice to the provider and the prior authorization request will result in an adverse benefit determination, Parkland Community Health Plan will refer the incomplete prior authorization request to the Medical Director with all information received in the initial request. The determination should be completed within 3 business days of the referral to the Medical Director. 

Prior Authorization Metric Reporting

To comply with the Centers for Medicare & Medicaid Services (CMS) interoperability and prior authorization final rule, starting in 2026 impacted payers must publicly report certain prior authorization metrics from the previous calendar year on their websites.

Annual Reports & Change Logs

To review the STAR (Medicaid) prior authorization annual review report and change log, please reference:

To access Prior Authorization Request forms for applicable services, visit PCHP’s Provider Forms webpage.