Prior authorization requests
Submit the Texas Standard Prior Authorization Request Form online and get your case reference number right away.
You can also call 855-579-3879
325-603-0541, with the request form (PDF)
Submit a prior authorization request online
Fill in the request, attach your clinical documents and get your case reference number right away.
Upload an inpatient notification form
- 1Complete the notification form
Fill in the inpatient notification form (PDF).
- 2Gather clinical documentation
Admission notes and the clinical documentation that supports the stay.
- 3Upload it all here
Our clinical team reviews it and calls you if anything is missing.
What to include
- The completed inpatient notification form, with the patient’s member ID and date of birth.
- NPI numbers for the requesting and servicing providers.
- CPT/HCPCS and ICD-10 codes for the services and diagnoses.
- Clinical documentation supporting the requested services.
- For urgent requests, you can also call 855-579-3879.
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