Prior authorization requests

Submit the Texas Standard Prior Authorization Request Form online and get your case reference number right away.

Urgent request?

You can also call 855-579-3879

Prefer to fax?

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.

Start a request

Upload an inpatient notification form

  1. 1
    Complete the notification form

    Fill in the inpatient notification form (PDF).

  2. 2
    Gather clinical documentation

    Admission notes and the clinical documentation that supports the stay.

  3. 3
    Upload 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.

Enter a contact name and direct phone number so we can reach you if anything is missing from your submission.

Attach your inpatient notification form with supporting clinical documentation. PDF, Word documents or images, up to 30 MB combined. Tip: select all your files at once and drag them in together.

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