Prior Authorization

To ensure El Paso Health has all it needs to initiate a prior authorization request you will need to submit the Texas Standard Prior Authorization Request Form for Health Care Services or for behavioral health the Behavioral Health Prior Authorization Form

The form must include the following essential information:

If El Paso Health receives a request for prior authorization with information that is incomplete, missing, incorrect, or illegible El Paso Health will not enter the request in our system and will not approve or deny the request. El Paso Health will return the request and provide an explanation by fax of why it is unable to be processed. You will need to resubmit the rejected prior authorization request with completed information.

The following supporting clinical documentation will be needed for El Paso Health to initiate and complete a review. Including, but not limited to:

If El Paso Health receives a request for a Medicaid member that does not have complete or is missing supporting clinical documentation, El Paso Health will send a fax to the requesting provider no later than 3 Business Days after the prior authorization is received describing the specific list of what needs to be submitted and the date when it’s due.

If the information requested is not received by the end of the 3rd Business Day from the date El Paso Health sent the notice to the provider and the PA request will result in an Adverse Determination El Paso Health will send the request to the Medical Director for review with all information received with the PA request no later than the 7th Business Day after the PA receive date. The Medical Director may take up to 3 Business Days to complete the review and make a final determination. No later than the 10th Business Day from when the PA was received El Paso Health will make a final decision on the PA request.

A peer to peer consultation is available at any time during the PA process after an El Paso Health Medical Director review. El Paso Health will offer an opportunity for a peer to peer consultation to the requesting physician no less than one Business Day before an Adverse Determination is issued.
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El Paso Health will use one or more of following proprietary or internally developed guidelines to determine whether to approve a prospective, concurrent, or retrospective review for medical necessity and appropriateness of the health care services:

El Paso Health will provide a determination of a review within the following timelines:

Standard/Routine
Within three (3) business days after receipt of the request

Expedited/Urgent
Within one (1) business day after receipt of the request

Inpatient
Within one (1) business day after receipt of the request

Post-Stabilization
Within one (1) hour of receipt of request, if the request is related to post-hospitalization or life-threatening conditions, except that for Emergency Medical Conditions and Emergency Behavioral Health Conditions, EPH will not require prior authorization.

If you have questions or need help with the prior authorization process please don’t hesitate to call El Paso Health Monday through Friday from 8:00 a.m. to 5:00 p.m. MST (excluding holidays) at the following number:

Members:
915-532-3778 or toll-free 1-877-532-3778 at extension:

CHIP: 1516 (English), 1519 (Spanish)
STAR: 1513 (English), 1518 (Spanish)

Providers:
915-532-3778 or toll-free 1-877-532-3778 at extension:

CHIP: 1517
STAR: 1514

STAR+PLUS Members/Providers:
Toll Free 1-833-742-3127
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Providers can submit Pharmacy Prior Authorizations (PA) for Outpatient Drugs to El Paso Health’s Pharmacy Provider Hotline at 1-877-908-6023. Clinical staff is available 24 hours a day, 7 days a week. Providers may also fax prior authorization forms to El Paso Health’s Pharmacy Prior Authorization at 1-855-668-8553.

PHARMACY PRIOR AUTHORIZATION TIMELINES:

For medication specific PA forms click here or submit the Texas Standard Prior Authorization Request Form for Prescription Drug Benefit.
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