About Notifications and Prior Authorizations

Some services require notifications or prior authorization. All out-of-network physician, hospital, or ancillary service requests require prior authorization.

Notification and Prior Authorization Lists

Medical and Behavioral Services

Medical Services Prior Authorization List (Effective 1/1/2020)

RightCare Prior Authorization List (Effective 4/1/2023)

RightCare Authorization Request Form & Instructions

Behavioral Health Referral Authorization Form and Instructions

Medical Coverage Policies

Medical Policy and Prior Authorization Update Notices

Prior Authorization Process

Certain services require authorization in order to be covered by RightCare. 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. Prior authorization requests must be received before the services are provided to the member. Failure of a provider to contact RightCare for the required prior authorization of services and/or rendered prior to notifying RightCare will relieve both RightCare and the member from any financial responsibility for the service(s) in question.

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

Prior authorization is sometimes called pre-certification or pre-notification. 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, Baylor will also verify if the Member has benefits.

Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Baylor must still process a Providers claim to determine if payment will be made.

Prior Authorization Requests: Essential Information & Supporting Clinical Documentation

Providers must submit the Prior Authorization Request Form, which you can view and download here.

Supporting Clinical Documentation

• Authorization Required List
• Supporting Documentation List
• Medicaid Statistics

Lack of Information

Essential Information to Initiate an Authorization

If you submit a prior authorization request that includes all Essential Information, we will process the request following our established timelines and guidelines. If Essential Information is missing, incorrect, or illegible, we will be unable to make a decision. We will return all requests that are missing Essential Information to you with an explanation of why it was not processed and instructions for resubmission.

A prior authorization request must include the following Essential Information:

• 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

Complete Authorization Requests

As a reminder, authorization requests must include all information and documentation that is required to make a medical or functional necessity determination. Submit all required information and documentation for your prior authorization request through our portal, by fax, or by calling us at 855-691-7947.

In addition, requests for outpatient prior authorization submitted through our portal require that clinical information be added prior to submission. To be considered a complete request, the following clinical information from the past 12 months (but not limited to) must be submitted:

• 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

Incomplete or Insufficient Documentation

The following process applies when we receive incomplete prior authorization requests that are missing Essential Information for Medicaid members:

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.

Prior Authorization Timeline

• 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.

Prior Authorization Annual Review Report

• PA Change Log (9_2024)
• PA Annual Review Report (9_2024)

Prior Authorization Assistance

To obtain a prior authorization assistance, RightCare in-network providers are encouraged to log in to the RightCare Provider Self-Service portal to verify eligibility status and utilize the Authorization Code Look-up to submit new authorization requests, view authorization status, and view prior authorization requirements. Alternately, complete the Essential Information to Initiate an Authorization on the RightCare Authorization Request Form and submit the Complete Authorization Request via fax to 800-292-1349. Appropriate personnel are available to respond to utilization review inquiries 8 a.m. to 5 p.m. weekdays with a telephone system capable of accepting utilization review inquiries outside of these hours. Please call toll-free at 855-691-7947 for medical prior authorization and 855-395-9652 for behavioral prior authorization.

To obtain a pharmacy prior authorization assistance, please call RightCare’s PBM, Navitus, toll free at 877-908-6023, and select the prescriber option to speak with the Prior Authorization department between 6 a.m. to 6 p.m. Central Time weekdays and 8 a.m. to noon CT weekends, excluding state approved holidays.

To obtain prior authorization assistance for members, please call 855-TX-RIGHT (897-4448) from 7 a.m. to 7 p.m. CT weekdays (except state-approved holidays) TTY: 711.

Pharmacy Notifications and Prior Authorizations

RightCare is state mandated to adhere to the Texas Medicaid formulary and Preferred Drug List, which are developed and maintained by the Texas Drug Utilization Review (DUR) Board and Texas HHSC Vendor Drug Program (VDP). Additional information regarding VDP including formularies, preferred drug list, and Texas DUR Board meeting minutes and updates can be found on the Texas Vendor Drug Program webpage.

RightCare administers the prior authorization criteria approved by the Texas DUR Board.

• Listing of Clinical Edits Implemented by RightCare
• RightCare's Prior Authorization Forms

Pharmacy Prior Authorization Timeline

• 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.
  More information

  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 877-908-6023 or RightCare at 855-897-4448 for more information about the 72-hour emergency prescription supply policy.