Prior Authorization Request Form - Texas Medicaid - Clinical Prior Authorization Submission

Sep 17, 2026

Upload by Quinn

Prior Authorization Request Form for Texas Medicaid (Wellpoint) to request review and approval for covered services. Instructions emphasize completing all fields to avoid processing delays and submitting the form with required clinical information, provider contact details, and supporting documents. The form collects member demographics, referring and servicing provider details, requested services with ICD-10 and CPT codes, type and place of service, and review urgency (urgent or emergent). It also supports benefit exceptions and includes facility information when applicable.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Member information

Referring provider

Servicing provider

Coverage details

Servicing facility

Requested service and coding

Review type and urgency

Benefit exception and additional information

Prior Authorization Request Form Texas | Medicaid Wellpoint prior authorization: 833-731-2162 (phone); 800-964-3627 (fax) . To prevent delays in processing your request, please complete the form in its entirety with all applicable information. Requests for prior authorization may be submitted for review and approval via digital submission (preferred) at [https://www.Availity.com](https://www.Availity.com). | Today’s date: | | | | Provider return fax: | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Member information | | | | | | | | | | Member name: | | | | | Date of birth: | | | | | Wellpoint member ID: | | | | Contact phone: | | | | | | Address/City/State/ZIP code: | | | | | | | | | | Additional member information: | | | | | | | | | | Referring provider | | | ☐ Participating
☐ Nonparticipating | | | | | | | Full name: | | | | | | | NPI: | | | Specialty: | | | | | | Provider ID: | | | | Office contact name: | | | | Tax ID number (TIN): | | | | | | Office phone: | | | | Office fax: | | | | | | Address/City/State/ZIP code: | | | | | | | | | | Servicing provider | | | ☐ Participating
☐ Nonparticipating | | | | | | | Full name: | | | | | | | NPI: | | | Specialty: | | | | | | Provider ID: | | | | Office contact name: | | | | Tax ID number (TIN): | | | | | | Office phone: | | | | Office fax: | | | | | | Address/City/State/ZIP code: | | | | | | | | | Coverage provided by Wellpoint Insurance Company or Wellpoint Texas, Inc. TX-WP-CD-007954-26-S2323 | April 2026 | Servicing facility | ☐ Participating
☐ Nonparticipating | | | | --- | --- | --- | --- | | Facility name: | | | | | NPI: | | Provider ID: | | | Facility contact name: | | Tax ID number (TIN): | | | Facility phone: | | Facility fax: | | | Address/City/State/ZIP code: | | | | | Requested service (for type of service, check all that apply): | | Date/date range of service: | | | ICD-10 code(s): | | | | | CPT® code(s) (include requested units/visits): | | | | | Modifier(s): | | | | | Type of service: | ☐ Outpatient ☐ Planned inpatient ☐ Emergent inpatient
☐ Skilled nursing facility ☐ Long-term services & supports/long-term care ☐ Home health ☐ Diagnostic study ☐ Durable medical equipment
☐ Hospice ☐ Office visit ☐ Personal care services
☐ Other: | | | | Place of service: | ☐ Hospital ☐ Ambulatory surgery center ☐ Office
☐ Home ☐ Independent lab ☐ Nursing facility
☐ Other: | | | | Review type: | ☐ Urgent
☐ Nonurgent | Clinical reason for urgency: | | | Requesting a prior authorization for benefit exception (check box): | | | ☐ Yes
☐ No | | Additional information: | | | | Please submit all appropriate clinical information, provider contact information, and any other required documents with this form to support your request. If this is a request for an extension or modification of an existing authorization from Wellpoint, please include the authorization number in the final field, Additional information, with your submission. Emergent—use for all non-elective inpatient admissions only when the provider indicates that the admission was urgent, emergent, or expedited (for admission on the same day) . Urgent—use for outpatient services only when the provider indicates that the service is urgent, emergent, or expedited.

FAQs

How should prior authorization requests be submitted to Wellpoint?

Complete the form in its entirety with all applicable information and submit for review and approval via digital submission (preferred). Include required clinical information, provider contact information, and supporting documents.

What information must be provided about the member and providers?

Provide member information (name, date of birth, member ID, address, and contact phone) and provider details for the referring and servicing providers, including full name, specialty, NPI, provider ID, tax ID (TIN), office contact name, phones, and addresses.

How are urgent and emergent review types determined?

Emergent is used for all non-elective inpatient admissions only when the provider indicates the admission was urgent, emergent, or expedited (same day). Urgent is used for outpatient services when the provider indicates the service is urgent, emergent, or expedited.

Sep 17, 2026

Upload by Quinn