Texas Standard Prior Authorization Request Form for Health Care Services - Section I to VI - Submission and Provider/Clinical Documentation

Sep 17, 2026

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Texas Standard Prior Authorization Request Form for Health Care Services provides instructions and structured fields for submitting prior authorization requests to an issuer for health care services. It explains correct submission routes, states when urgent review is appropriate, and defines what the form cannot be used for (e.g., appeals, eligibility, referrals, or prescription prior authorization). Sections cover submission, general review/request type details, patient information, provider information rules, and clinical documentation requirements, including medical necessity narratives and supporting records.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Before completing form

Submission instructions

Intended use and exclusions

Section I — Submission

Issuer entry and website copy

Section II — General information

Review type and request type

Section III — Patient information

Section IV — Provider information

Signature and PCP guidance

Section V — Services requested and diagnoses

CPT/CDT/HCPCS and ICD coding

Section VI — Clinical documentation

Medical necessity narrative and attachments

Texas Standard Prior Authorization Request Form for Health Care Services NOFR001 | 0415 Texas Department of Insurance before completing form form Please read all instructions below this . Please send this request to the issuer from whom you are seeking authorization. Do not send this to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or subscriber’s employer. Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standard Prior Authorization Request Form for Health Care Services if the plan requires prior authorization of a health care service. In addition to commercial issuers, the following public issuers must accept the form: Medicaid, the Medicaid managed care program, the Children’s Health Insurance Program (CHIP), and plans covering employees of the state of Texas, most school districts, and The University of Texas and Texas A&M Systems. Intended Use: Use this form to request authorization by fax or mail when an issuer requires prior authorization of a healthcare service. An Issuer may also provide an electronic version of this form on its website that you can complete and submit electronically, through the issuer’s portal, to request prior authorization of a health care service. Do not use this form to: 1) request an appeal; 2) confirm eligibility; 3) verify coverage; 4) request a guarantee of payment; 5) ask whether a service requires prior authorization; 6) request prior authorization of a prescription drug; or 7) request a referral to an out of network physician, facility or other health care provider. Additional Information and Instructions: Section I – Submission: An issuer may have already entered this information on the copy of this form posted on its website. Section II – General Information: Urgent reviews: Request an urgent review for a patient with a life-threatening condition, or for a patient who is currently hospitalized, or to authorize treatment following stabilization of an emergency condition. You may also request an urgent review to authorize treatment of an acute injury or illness, if the provider determines that the condition is severe or painful enough to warrant an expedited or urgent review to prevent a serious deterioration of the patient’s condition or health. Section IV – Provider Information: • If the Requesting Provider or Facility will also be the Service Provider or Facility, enter “Same.” • If the requesting provider’s signature is required, you may not use a signature stamp. • If the issuer’s plan requires the patient to have a primary care provider (PCP), enter the PCP’s name and phone number. If the requesting provider is the patient’s PCP, enter “Same.” Section VI – Clinical Documentation: • Give a brief narrative of medical necessity in this space, or in an attached statement. • Attach supporting clinical documentation (medical records, progress notes, lab reports, etc. ), if needed. Note: Some issuers may require more information or additional forms to process your request. If you think more information or an additional form may be needed, please check the issuer’s website before faxing or mailing your request. Note: If the requesting provider wants to be called directly about missing information needed to process this request, you may include the provider’s direct phone number in the space given at the bottom of the request form. Such a phone call cannot be considered a peer-to-peer discussion required by 28 TAC §19.1710. A peer-to-peer discussion must include, at a minimum, the clinical basis for the URA's decision and a description of documentation or evidence, if any, that can be submitted by the provider of record that, on appeal, might lead to a different utilization review decision. TEXAS PRIOR AUTHORIZATION REQUEST FORM SECTION I —SUBMISSION Sendero Health Services Phone: 1-855-297-9191 Fax: 512-901-9724 Web Authorizations may be completed [at](at

FAQs

Where should the completed prior authorization request form be sent?

Send the request to the issuer from whom authorization is sought. Do not send it to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s/subscriber’s employer.

When can an urgent review be requested using this form?

Request an urgent review for life-threatening conditions, for hospitalized patients, or to authorize treatment after stabilization of an emergency condition. It may also be requested for acute injury or illness when severe or painful enough to warrant expedited review to prevent serious deterioration.

What information must be provided in the clinical documentation section?

Include a brief narrative of medical necessity in the space provided or an attached statement. Attach supporting clinical documentation such as medical records, progress notes, and lab reports if needed.

Sep 17, 2026

Upload by Rhys