To request coverage approval from Texas Children’s Health Plan, complete the Texas Children’s Health Plan prior authorization form (a single-page PDF posted under provider resources at texaschildrenshealthplan.org) and send it to the Utilization Management department either through the Texas Children’s Link provider portal or by fax on the line that matches the service type. The portal is faster, supports auto-approval on certain services, and shows real-time status; fax is accepted as a fallback.
Where to Get the Form
TCHP publishes the Prior Authorization Request Form as a downloadable PDF on its website. One form covers medical, surgical, and equipment requests across all of the plan’s product lines, including STAR, STAR Kids, and CHIP. The same provider resources page also lists the current prior authorization service list, the fax numbers, and contact information for the Utilization Management team.
If you plan to submit online instead, the authorization functions are built into the Texas Children’s Link portal directly, so you won’t need the PDF at all.
How to Fill Out the Form
The form is organized into administrative, clinical, and service-setting sections. Getting it right the first time avoids the back-and-forth that stalls decisions.
Member and Provider Information
Enter the member’s full legal name, date of birth, sex, and Medicaid or CHIP ID number. The ID is the nine- or ten-digit number printed on the Texas Medicaid card. A single wrong digit can hold up the entire request.
The form asks for multiple NPIs: the primary care provider’s NPI, the requesting provider’s NPI, and the rendering or pay-to-affiliate NPI if a different entity will bill for the service. A facility NPI goes in its own field. Include the name of the person completing the form along with office phone and fax numbers, so the UM team can reach someone directly if questions come up.
Clinical Details
Use ICD-10-CM codes for the diagnosis. List the specific service or procedure requested with the corresponding CPT or HCPCS codes, the requested date of service, and the number of visits or units needed. For inpatient requests, include the estimated length of stay in days.
The medical history box on the form is small. Use it for a short clinical summary and attach the full supporting records separately. The place-of-service field offers checkboxes for inpatient, observation, outpatient, home, physician’s office, and day surgery.
Other Insurance
If the member has additional coverage, note the other insurer’s name and phone number so TCHP can coordinate benefits and determine which payer is primary.
What to Attach
The form is only a cover sheet. The attached clinical documentation is what the UM reviewers actually use to decide whether the service is medically necessary and matches the diagnosis.
At a minimum, send recent office visit notes describing the member’s current condition, any relevant lab results or imaging reports, and documentation of previous treatments that were tried and failed. For durable medical equipment, include a detailed description of the member’s functional limitations and how the specific equipment addresses them. For therapy requests, spell out the treatment plan’s goals, duration, and frequency.
For mental health targeted case management and rehabilitative services, the provider must also hold current CANS or ANSA certification, updated annually, and send a copy to TCHP’s network management team.
How to Submit the Form
Texas Children’s Link Portal
The portal is TCHP’s preferred channel. Requests submitted this way reach the UM team faster than any other method and can qualify for auto-authorization on certain straightforward services. You can also check whether a request is pending, approved, or denied without calling. Both clinical and non-clinical staff can submit and review requests on behalf of a provider.
Fax
If you fax, use the line that matches the service. Sending a request to the wrong queue adds delay.
- Medical services: 832-825-8760 (toll-free 1-844-473-6860)
- Medical inpatient admissions and discharge notifications: 832-825-8462 (toll-free 844-663-7071)
- Behavioral health services: 832-825-8767 (toll-free 1-844-291-7505)
- LTSS and private duty nursing: 346-232-4757 (toll-free 1-844-248-1567)
- Hospital discharge authorizations for members currently hospitalized who need equipment or services immediately after discharge: toll-free 866-839-9879
Keep the fax confirmation page as proof of your submission date. If you haven’t heard back within a few business days, call the provider line at 1-800-731-8527 to confirm receipt. The Utilization Management team is available Monday through Friday, 8 a.m. to 5 p.m. Central.
When You Actually Need to File
TCHP’s prior authorization list is longer than most providers expect, but it isn’t universal. The current list covers:
- Inpatient care, including hospital admissions, inpatient procedures, inpatient psychiatric care, and detoxification
- Occupational, physical, and speech therapy, excluding early childhood intervention programs, reevaluations, and acute therapy evaluations billed with the AT modifier
- Durable medical equipment such as wheelchairs and accessories, hospital beds, mobility aids, CPAP/BiPAP devices, and miscellaneous DME when the billed amount exceeds $500
- Imaging including fetal MRI, PET scans, and SPECT scans
- Bariatric surgery, cosmetic surgery, functional endoscopic sinus surgery, and oral surgery
- Outpatient psychotherapy visits beyond 30 per year, intensive outpatient programs, and partial hospitalization
- Genetic testing, transplants, autism services (ABA therapy), home health, private duty nursing, and non-emergency ambulance transport
- Any service delivered by an out-of-network provider
Prior authorization is not required for emergency medical conditions or emergency behavioral health conditions. Providers do not need to obtain approval before treating a member in an emergency.
What Happens After You Submit
Once a complete request is received, the UM team reviews it against Texas Medicaid medical necessity criteria for the member’s program. Pharmacy requests move fastest: TCHP processes routine and urgent drug requests within 24 hours.
For medical service requests, HHSC’s Uniform Managed Care Manual sets the outer limits. If the request is complete, TCHP must decide within the timeframe in its managed care contract. If the request is incomplete, TCHP must notify the provider in writing within three business days of what’s missing. After that notification, the plan has until the tenth business day from the original receive date to issue a final decision, and the entire process cannot exceed 14 calendar days.
Before issuing a denial, TCHP must give the requesting physician at least one business day’s notice and an opportunity for a peer-to-peer consultation. That conversation is often the fastest way to resolve a disagreement about medical necessity without a formal appeal.
When a request is approved, TCHP assigns a unique authorization number. Put that number on the claim you submit for payment. Without it, the claim will be denied even though the service was authorized. Both the provider and the member receive written notification of the decision no later than the next business day after it’s made.
If the Request Is Denied
Providers who submit additional clinical documentation often succeed on appeal.
First-Level Appeal
Providers have 60 calendar days from the denial to request a medical necessity appeal. Send a written request explaining why you disagree with the decision, along with any new supporting medical documentation, to:
Texas Children’s Health Plan
Attention: UM Appeals Department
PO Box 300709 WLS 8390
Houston, TX 77230
Fax: 832-825-8796
TCHP acknowledges the appeal in writing within five business days and may request specific additional medical information. If that information isn’t provided within 10 days, the plan decides on what it already has. The standard appeal decision comes within 30 calendar days. If the medical records still haven’t arrived by the 30th day after filing, the original denial stands and the provider’s appeal rights with TCHP are exhausted.
Expedited Appeals
When a member’s medical condition could be jeopardized by waiting 30 days, providers can fax an expedited review request to the same number, 832-825-8796. TCHP responds to expedited appeals involving emergency services or continued hospitalization within one business day.
Second-Level Specialty Review
If the first appeal is denied, providers can ask for a second review by a different physician in the same or a similar specialty. File the request in writing within 30 calendar days of receiving the first appeal decision and explain why a specialty review is warranted. TCHP completes the specialty review within 15 business days.
Members have a separate path to a State Fair Hearing through HHSC after exhausting internal appeals, with its own 120-day filing window.
Skipping the Form With a Gold Card Exemption
Texas law gives high-performing providers a way to bypass prior authorization entirely. Under Insurance Code Chapter 4201 (originally enacted as HB 3459), a provider qualifies for a preauthorization exemption, commonly called “gold carding,” for a specific service if they submitted at least five prior authorization requests for that service during the most recent 12-month evaluation period and were approved on 90% or more.
Once a provider earns the exemption, the health plan cannot require prior authorization or any similar utilization review for that service. The exemption is granted at the issuer level, so it applies across TDI-regulated plans from the same insurer. It stays in effect unless the plan rescinds it, and rescission can only happen in January of a year that falls on or after the first anniversary of the evaluation period’s end date. If a review shows the approval rate for that service dropped below 90%, the exemption ends.
Providers denied a gold card exemption on or after September 1, 2025 can request an independent review of that decision. An Independent Review Organization assigned by the Texas Department of Insurance re-examines the adverse determinations that led to the denial. If the IRO disagrees with any of those denials, those requests count as approved for the 90% calculation.