Texas Standard Prior
Authorization Request Form for
Health Care Services
Mail this form to:
P O Box 14079
Lexington, KY 40512-4079
For fastest service call 1-888-632-3862 Monday – Friday 8:00 AM to 6:00 PM Central Time
Please read all instructions below before completing this form.
Please send this request to the issuer from whom you are seeking authorization. Do not send this form to the
Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or
subscriber’s employer.
Beginning S
eptember 1, 2015, health benefit plan issuers must accept the Texas Standardized Prior Authorization
Request Form for Health Care Services if the plan requires prior authorization of a health care service.
In addition to commercial issuers, the following public issuers must accept the form: Medicaid, the Medicaid
managed care program, the Children’s Healt
h Insurance Program (CHIP), and plans covering employees of the
state of Texas, most school districts, and The University of Texas and Texas A&M Systems.
Intended Use: Use this form to request authorization by fax or mail when an issuer requires prior authorization of
a health car
e service. An Issuer may also provide an electronic version of this form on its website that you can
complete and submit electronically, through the issuer’s portal, to request prior authorization of a health care
service.
Do not use this form to: 1) request an appeal; 2) confirm eligibility; 3) verify coverage; 4) request a guarantee of
payment; 5)
ask whether a service requires prior authorization; 6) request prior authorization of a prescription drug;
or 7) request a referral to an out of network physician, facility or other health care provider.
Additional Information and Instructions:
Section 1 – Submission:
An issuer may have already entered this information on the copy of this form posted on its website.
Section 2 – General Information:
Urgent reviews: Request an urgent review for a patient with a life-threatening condition, or for a patient who is
currently hospitali
zed, or to authorize treatment following stabilization of an emergency condition. You may also
request an urgent review to authorize treatment of an acute injury or illness, if the provider determines that the
condition is severe or painful enough to warrant an expedited or urgent review to prevent a serious deterioration of
the patient’s condition or health.
Section 5 – Provider Information:
• If the Requesting Provider or Facility will also be the Service Provider or Facility, enter “Same.”
• If the requesting provider’s signature is required, you may not use a signature sta
mp.
• If the issuer’s plan requires the patient to have a primary care provider (PCP), enter the PCP’s name and phone
number. If the requestin
g provider is the patient’s PCP, enter “Same.”
Section 6 – Clinical Documentation:
• Give a brief narrative of medical necessity in this space, or in an attached statement.
• Attach supporting clin
ical documentation (medical records, progress notes, lab reports, etc.), if needed.
Note: Some issuers may require more information or additional forms to process your request. If you think more information or an
additional form may be needed, please check the issuer’s website before faxing or mailing your request.
Note: If the requesting provider wants to be called directly about missing information needed to process this request, you may
include the provider’s direct phone number in the space given at the bottom of the request form. Such a phone call cannot be
considered a peer-to-peer discussion required by 28 TAC §19.1710. A peer-to-peer discussion must include, at a minimum, the
clinical basis for the URA's decision and a description of documentation or evidence, if any, that can be submitted by the provider
of record that, on appeal, might lead to a different utilization review decision.
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