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The form instructs submitters not to use it for appeals, eligibility confirmations, coverage verification, guarantees of payment, prescription-drug prior authorization, or out-of-network referrals. It provides rules for urgent reviews, submission handling, requesting and service provider details, clinical documentation, and required supporting information including medical necessity and diagnosis codes.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/texas-standard-prior-authorization-request-form-for-health-care-services-submission-instructions/288450/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/texas-standard-prior-authorization-request-form-for-health-care-services-submission-instructions/288450.png","ImageObject",442,249,{"name":88,"@type":89},"Sarah ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should this prior authorization request be submitted?","Question",{"text":108,"@type":109},"Submit the request to the issuer by fax or mail, using the contact details listed on the form. 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Urgent review can also apply when the provider determines the condition is severe or painful enough to warrant an expedited decision to prevent serious deterioration.",{"name":115,"@type":106,"acceptedAnswer":116},"What should not be requested using this form?",{"text":117,"@type":109},"Do not use the form to request an appeal, confirm eligibility, verify coverage, request a guarantee of payment, ask whether a service requires prior authorization, request prior authorization of a prescription drug, or request a referral to an out-of-network physician, facility, or other provider.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288450,1790133337,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Texas Standard Prior Authorization Request Form for Health Care Services  \nMail this form to:  \nP O Box 14079 Lexington, KY 40512-4079  \nFor fastest service call 1-888-632-3862 Monday – Friday 8:00 AM to 6:00 PM Central Time  \nPlease read all instructions below before completing this form.  \nPlease send this request to the issuer from whom you are seeking authorization. Do not send this form to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or subscriber’s employer.  \nBeginning September 1, 2015, health benefit plan issuers must accept the Texas Standardized Prior Authorization Request Form for Health Care Services if the plan requires prior authorization of a health care service.  \nIn 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.  \nIntended Use: Use this form to request authorization by fax or mail when an issuer requires prior authorization of a health care 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.  \nDo 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.  \nAdditional Information and Instructions:  \nSection 1 – Submission:  \nAn issuer may have already entered this information on the copy of this form posted on its website.  \nSection 2 – General Information:  \nUrgent 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.  \nSection 5 – Provider Information:  \n• If the Requesting Provider or Facility will also be the Service Provider or Facility, enter “Same.”  \n• If the requesting provider’s signature is required, you may not use a signature stamp.  \n• 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.”  \nSection 6 – Clinical Documentation:  \n• Give a brief narrative of medical necessity in this space, or in an attached statement.  \n• Attach supporting clinical documentation (medical records, progress notes, lab reports, etc.), if needed.  \nNote: 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.  \nNote: 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.  \nGR-69125 (4-18) Page 1 of 2  \nTexas Standard Prior Authorization Request ","cbCaibfixooIB6Iq","https://ap.wps.com/l/cbCaibfixooIB6Iq","pdf",572941,"English","# Section 1 – Submission\n# Section 2 – General Information\n# Section 3 – Patient Information\n# Section 4 – Provider Information\n# Section 5 – Services Requested and Supporting Diagnoses\n# Section 6 – Clinical Documentation","[{\"question\":\"How should this prior authorization request be submitted?\",\"answer\":\"Submit the request to the issuer by fax or mail, using the contact details listed on the form. Some issuers may also provide an electronic version via their website or portal.\"},{\"question\":\"When can an urgent review be requested?\",\"answer\":\"Request an urgent review for a life-threatening condition, for a hospitalized patient, or to authorize treatment after stabilization of an emergency condition. Urgent review can also apply when the provider determines the condition is severe or painful enough to warrant an expedited decision to prevent serious deterioration.\"},{\"question\":\"What should not be requested using this form?\",\"answer\":\"Do not use the form to request an appeal, confirm eligibility, verify coverage, request a guarantee of payment, ask whether a service requires prior authorization, request prior authorization of a prescription drug, or request a referral to an out-of-network physician, facility, or other provider.\"}]","Texas Standard Prior Authorization Request Form for Health Care Services - Submission Instructions | PDF",1789633497]