Submit a prior authorization request
The Texas Standard Prior Authorization Request Form, online. Attach your clinical documents and get your case reference number as soon as we receive it.
Urgent request?
You can also call 855-579-3879
Prefer to fax?
Fax the PDF form and your clinical documents to 325-603-0541
- 1Request form
- 2Review
- 3Confirmation
Fill in the request, attach your clinical documents and submit. Fields marked optional can be left blank.
Before you start
- Have ready: the member ID, the requesting and servicing NPIs, the CPT or HCPCS and ICD-10 codes, and your clinical documents (PDF, JPG, PNG or DOCX).
- Don’t use this form to request an appeal, confirm eligibility, verify coverage, request a guarantee of payment, ask whether a service needs prior authorization, request prior authorization of a prescription drug, or request a referral to an out-of-network provider.
- Prefer to fax? Download the PDF form, fill it in and fax it with your clinical documents to 325-603-0541.