Prior auth request and lookup

Prior authorizations

Learn about our prior authorization process and get helpful information to request coverage approval for your patients. Prior Authorization occurs before planned inpatient admissions and select healthcare services on the prior authorization requirements list below.

Benefits of prior authorization:

• to assure members health benefits are administered appropriately
• members receive treatments that are proven to be safe and effective for the condition being treated
• members and their appointed representatives will know coverage decisions before procedures, services or supplies are provided
• identification of members to pair them with specialty programs with case management and disease management

The prior approval process is called prior authorization, or prior authorization (PA). Providers can submit prior authorization requests on behalf of their patients. The prior authorization process is part of the Utilization Review (UR) activities performed by Evry Health. Please note, prior authorizations through the Utilization Review process are not intended to provide medical advice or medical care. Medical advice and care should be discussed with treating providers.

For information on the prior authorization for pharmacy benefits, see this website here (opens in a new tab).

Screening criteria

Reviews for determining medical necessity for inpatient and outpatient services are performed utilizing initial eligibility of benefits for coverage and the following resources or criteria may be used during the determination process for medical necessity review:

• State and Federal Guidelines
• Proprietary Medical Policies
• MCG Guidelines
• American Society of Addiction Medicine Criteria (ASAM) Criteria
• Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment Centers Texas Administrative Code (state.tx.us)

Other information sources to help to determine medical necessary and benefits coverage may include: Up to Date® applicable to the clinical situation, National Comprehensive Cancer Network (NCCN) Guidelines, Reference to other Health Plan policies (comparing accepted standards).

Prior authorization submission process

For authorization handled by Evry, providers may request authorization by the following process:

1. 1

   Complete the Texas Standard Prior Authorization Request Form* available for download here (PDF).

2. 2

   Once completed, please fax the completed prior authorization request form along with the required documentation listed below to request prior authorization. Completion of the form with supporting documentation is required to complete a medical necessity review.

Documentation requirements

Essential elements necessary to be submitted with prior authorization requests include ALL of the following:

1. A.Completed prior authorization request form
2. B.Clinical Documentation supporting the requested services (including but not limited to):
   1. Medical History (include treatment, diagnostic tests, examination data)
   2. Description of treatment plan and treatment to date
   3. Diagnostic/Laboratory/Radiology results
   4. Clinical notes necessary to certify medical necessity

All determinations or requests for more information in order to make an initial UR determination are made in a timely fashion appropriate for the member’s specific condition, not to exceed the timeframes required by NCQA, Texas state, and/or federal regulations. Decisions are communicated both verbally and/or in writing to providers and members, as required by regulations. To verify member eligibility, benefits, or account information, the provider should contact the Plan utilizing the customer service telephone number(s) available on the member’s identification card and/or the Plan website www.evryhealth.com.

Prior authorization requirement list

All Requirements are effective as of 06/01/2022. For a list of updated prior authorization requirements for medical services see prior authorization list updates for medical services. See services requiring prior authorization below.

Prior authorization is required before the service is provided in non-emergent situations. Retroactive requests will be denied unless there are extenuating circumstances. All prior authorizations should be requested using Evry Health Plan’s request form. Supporting documentation (e.g., notes and lab or radiology findings) should be sent with all prior authorization requests.

Please call to check the status of an existing authorization or inquire if a procedure or healthcare service requires prior authorization.

Services requiring prior authorization

• Services being performed in the Emergency Department do NOT require prior authorization.
• ALL services being performed or ordered by a non-participating provider REQUIRES prior authorization for members with EPO coverage.
• Admission to an inpatient facility, intensive outpatient (IOP), partial hospitalization (PHP), and residential treatment center (RTC) that are not directly from an ER. Emergency screening and stabilization services are not subject to authorization.
• See below for additional services requiring authorization.

Services requiring authorization