DRISCOLL HEALTH PLAN - INSTRUCTIONS FOR OBTAINING PRE-AUTHORIZATION FOR OPHTHALMOLOGY SERVICES

Sep 17, 2026

Upload by James

Instructions for obtaining pre-authorization for ophthalmology services under the Driscoll Health Plan via Envolve Vision. The guidance lists required pre-authorization circumstances, including specific CPT codes, use of participating providers/facilities, unlisted procedures, and experimental or investigational services. It outlines submission timing (at least 14 calendar days for non-emergent cases), required documentation and coding, and secure submission options by email, fax, or utilization management contact. It also explains review timelines and emergent/retrospective handling plus the Texas Standard Prior Authorization Request Form usage.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Pre-authorization requirements

Services requiring pre-authorization

Submission timing and documentation

How to submit requests

Review process and outcomes

Approval

Denial and peer-to-peer conference

Provider verification of status

Emergency procedures

Definition of emergent care

Retrospective review process

Texas Standard Prior Authorization Request Form

Intended use

DRISCOLL HEALTH PLAN--INSTRUCTIONS FOR OBTAINING PRE-AUTHORIZATION FOR OPHTHALMOLOGY SERVICES The following services requires pre-authorization by Envolve Vision • The following CPT codes regardless of where the service is performed: 15822, 15823, 66821, 66982, 67900, 67904, 67908 and anti-VegF injectables excluding Avastin (J9035) • Any service provided by a non-participating provider or at a non-participating facility • Any procedure code considered an unlisted procedure as defined by the AMA Current Procedural Terminology (CPT) manual (CPT codes 6xx99) • Experimental and investigational services For non-emergent procedures, the provider should submit a request to Envolve Vision at least 14 calendar days prior to the planned service date. Post-service requests for non-emergent procedures will not be processed. Providers will be required to submit a claim and/or claim appeal for consideration. Please follow the instructions listed below when requesting a pre-authorization review: • Ensure the attached Pre-Authorization Request Form is completely filed out, including both office and facility address and TIN – please use the “Section VI” area of the Texas Standard Prior Authorization Request Form for this information • Requests for Anti-VEGF Injectables must also include the Pre-Authorization Request for Anti-VEGF Injectables form at [https://www.envolvevision.com/providers/provider-forms.html](https://www.envolvevision.com/providers/provider-forms.html) • Pre-authorization requests must include coding for all procedures planned • The completed form and supporting clinical documentation (including original color photos for blepharoplasty/ptosis procedures) should be sent via secure email to [umauthorization@EnvolveHealth.com](umauthorization@EnvolveHealth.com. If you)[. If you](umauthorization@EnvolveHealth.com. If you) do not have access to a secure email program, contact the Utilization Management Department at 800-465-6972 and a reviewer will send you a secure email for reply with all required documentation attached. If you do not have the ability to email, you may fax your request at 877-865- 1077. • Providers should use participating Driscoll Health Plan facilities. All requests for non-participating facilities will require review by Driscoll Health Plan—Envolve Vision will forward your request to Driscoll Health Plan for non-par facility review • Please Note: If your planned service does not require authorization by Envolve Vision and you are using a participating Driscoll Health Plan facility, you do not need to request a facility authorization separately from Driscoll Health Plan Following receipt of your request: • After Envolve Vision has received the request, it will be entered into our system for review. If necessary, you may be contacted for additional information within 1 business day of receipt. • You will be notified within 3 business days upon completion of the review. o If the requested service is approved, an authorization letter will be faxed to your office. o If the requested service results in a denial, the requesting physician will be offered a peer-to-peer conference with the Envolve Vision Medical Director who made the denial. • Participating providers may utilize the Envolve Vision website to verify status of pre-authorization requests at [https://visionbenefits.envolvehealth.com/logon.aspx](https://visionbenefits.envolvehealth.com/logon.aspx) Emergency Procedures Emergent procedures do not require prior authorization. Services provided on an emergent basis in a non-participating facility should be submitted to Envolve Vision for retrospective review by the next business day after services have been rendered. Emergency care is defined by State of Texas Code as health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility to evaluate and stabilize medical conditions of a recent

FAQs

Which ophthalmology services require pre-authorization through Envolve Vision?

Pre-authorization is required for the listed CPT codes, services provided by a non-participating provider or facility, unlisted procedures (CPT 6xx99), and experimental or investigational services.

When should a non-emergent pre-authorization request be submitted?

For non-emergent procedures, submit the request to Envolve Vision at least 14 calendar days before the planned service date. Post-service requests for non-emergent procedures are not processed.

What happens after Envolve Vision receives a pre-authorization request?

The request is entered for review, and additional information may be requested within 1 business day. You are notified within 3 business days; approvals result in an authorization letter by fax, while denials offer a peer-to-peer conference with the Medical Director.

Sep 17, 2026

Upload by James