Clinical Prior Authorization Process
Clinical prior authorizations perform real-time reviews of a Medicaid client’s medical and drug claims histories.
Criteria Proposal and Implementation Process
HHSC establishes criteria based on the latest FDA-approved product labeling, national guidelines and peer-reviewed literature, and evidence-based clinical criteria. The Drug Utilization Review (DUR) Board reviews the prospective criteria proposed by Vendor Drug Program clinical staff, managed care organizations, and other stakeholders. Criteria are periodically revised to ensure that they reflect prescribing recommendations of the current compendia and literature.
Criteria Proposals For Medicaid Managed Care
Health plan staff should refer to Uniform Managed Care Manual (UMCM) chapter 3.29 ("MMC/CHIP MCO Pharmacy Website Required Critical Elements"). Proposals are submitted via email to both the Vendor Drug Program and the plan's health plan management team. Proposals must conform to manufacturer package insert information and not compromise HHSC’s supplemental rebate agreements with drug manufacturers who have products on the Medicaid Preferred Drug List. Proposals will be reviewed and responded to within 30 calendar days once received by VDP. HHSC’s response may include a request for additional information. Any incomplete proposal or proposals submitted in the incorrect format will not be reviewed.
Automated Authorization Process
Medicaid claims submitted at point-of-sale are subject to prior authorization criteria and are reviewed real-time against the client’s available medical and prescription drug claims histories to determine whether the client's condition meets the established criteria.
If the client’s history demonstrates the criteria are met, authorization will be approved. If the client's history does not meet the criteria, the pharmacy will receive a message indicating that the prescriber must request prior authorization.
- For fee-for-service Medicaid: the prescribing provider or provider representative must call the Texas Prior Authorization Call Center.
- For clients enrolled in Medicaid managed care: the prescribing provider or provider representative must call that health plan's prior authorization call center. Phone numbers will vary by plan. Plans are required to notify the prescriber’s office of a prior authorization approval/denial within 24 hours of the time of the request.
- Review the 72-hour emergency prescription override instructions. We encourage pharmacy staff to post these instructions in your pharmacy for easy reference and to reproduce this information for educational purposes with your staff.