Provider/Physician Notice
View the COVID-19 Telehealth and Telemedicine Policy for coding guidelines and claims submission procedures. We have also reduced our Prior Authorization Requirements.

Authorization Information

Preauthorization Code Search Tool

FirstCare in-network providers are encouraged to access the service code search tool via the FirstCare Provider Self-Service portal to submit new authorization requests, view authorization status, and view prior authorization requirements.

  • Enter one or more valid CPT or HCPCS codes into the tool and it will provide direction as to whether or not preauthorization is required as well as any exceptions or special instructions for the code(s) entered.

Alternately, providers can view the individual prior authorization list.

Prior Authorization List

​FirstCare Prior Authorization List

Medical Forms

Prior authorization requests, authorization check lists, treatment forms, clinical data forms, and more.

Medical Policies

FirstCare Medical Necessity Decision Policy

Medical

Medical Pharmacy

Behavioral Health Forms & Information

Forms and information for behavioral health services.

Prior Authorization Process

Certain services require authorization in order to be covered by FirstCare Health Plans. Authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment—including prescribed drug intervention—relative to approved evidence-based medical criteria.

Authorization is required to ensure that a requested medical service is medically necessary and that the member will receive the benefits to which they are entitled under their plan.

This page outlines information regarding prior authorization for services or medications obtained under the Medical benefit. For information regarding prior authorization for medications obtained under the Pharmacy benefit, reference the applicable plan page and refer to the pharmacy benefit section.

Prior Authorization Assistance

To obtain a pharmacy prior authorization assistance, please call FirstCare’s PBM, Navitus, Toll Free at 1-877-908-6023, and select the prescriber option to speak with the Prior Authorization department between 6 a.m. to 6 p.m. Monday through Friday, and 8 a.m to 12 p.m. Saturday and Sunday Central Time (CT), excluding state approved holidays.

Prior authorization requests must be received before the services are provided to the member. Failure of a network provider to contact FirstCare for the required prior authorization of services covered under the member’s plan and/or rendered prior to notifying FirstCare will relieve both FirstCare and the member from any financial responsibility for the service(s) in question.

 

FirstCare utilization management staff are available to receive authorization requests and to answer questions about authorization requirements or processes at 1-800-884-4905 (Monday through Friday, 6 a.m. to 6 p.m. CT, and from 9 a.m. to 12 p.m. CT on weekends and holidays). Requests may be submitted 24/7 online after logging in to the FirstCare Provider Self-Service portal. Requests may also be submitted via fax at 1-800-248-1852, 24 hours a day, 365 days a year.

Affirmative Statement About Incentives

Additional Requirements

  • All services, even if authorized, are subject to the member’s benefit plan contract coverage and exclusions, eligibility and network design. Approvals are not a guarantee of coverage, as the member’s benefit plan contract may retroactively terminate at a future date. Benefit plan contract exclusions and current status of eligibility may be verified by logging into the FirstCare Provider Self-Service portal. Out-of-network providers are encouraged to contact FirstCare’s Customer Service with any questions regarding benefit limitations.
  • All transplant services require prior authorization.
  • Cosmetic procedures are not covered for most plans. Please refer to the member's plan documents—Evidence of Coverage (EOC) or Certificate of Insurance (COI)—for further details as some reconstructive procedures may be covered if medical necessity criteria are met.
  • Home Health Requirements

  • Prior authorization is required for home health services. Services may include home health aide, occupational therapy, physical therapy, skilled nursing, speech therapy and/or social work. Prior authorization is not required for physical or occupational therapy evaluation.
  • The first visit for newly ordered home Skilled Nursing and home Speech Therapy requires authorization but will not require a prior authorization. FirstCare will retrospectively approve the initial nursing evaluation visit and/or speech therapy evaluation when the written evaluation and plan of care is received—within four (4) business days. Any additional services rendered during those four business days will also be retrospectively reviewed.
  • Inpatient Authorization Requirements

  • Services or codes listed within this document require prior authorization and will have a separate authorization number. 
  • For acute levels of inpatient care, FirstCare requires notification within 24 hours (or next business day for holiday weekends).
  • If, in the judgment of the rendering provider, the care is of an emergency or urgent nature, medical necessity review is required after the care begins.
  • Notification is required for obstetrical (OB) delivery when an associated inpatient stay is expected to exceed 48 hours post vaginal delivery or 96 hours post-cesarean delivery. 
  • Prior authorization on/before services are rendered is required for Inpatient Rehabilitation, Skilled Nursing Facility (SNF), Long term Acute Care (LTAC).
  • Out-of-Network Provider/Facility Services

  • Referrals to out-of-network providers must be pre-authorized and may be covered by FirstCare when one or more of the following conditions are present:
  • Life threatening emergency situation exists and delivery of services is appropriate or timely;
  • Access to an in-network facility or service is not reasonably practical or possible;
  • Medically necessary, covered medical service is not available through an in-network Provider;
  • Service or care is available in-network, but not accessible; and/or
  • Service is available in-network, but there is a continuity of care concern for a new member (e.g. any high risk pregnancy in the second trimester, a pregnancy in the third trimester or any other situation which, in the judgment of the Medical Director warrants an out-of-network authorization to complete a particularly complex episode of care).
  • Exceptions: Emergency Services. Rendering Medicaid providers must have a TPI.
  • Failure to obtain prior authorization for out-of-network services may result in a denial of payment for services rendered. Out-of-network providers should submit prior authorization requests by completing and faxing the FirstCare Prior Authorization Request Form.
  • All services that are considered experimental/investigational or potentially cosmetic require prior authorization.
  • Providers may contact FirstCare Health Plans to request a copy of the actual benefit provision, guideline, or other criteria on which a determination was made. For details on reaching out to FirstCare, please click here.
Providers are advised to leave their fax systems on at all times in order to receive correspondence from FirstCare (i.e. requests for additional clinical, options for peer-to-peer review, etc.) during and after business hours.

Essential Information to Initiate an Authorization

If the prior authorization request has Essential Information, the prior authorization request will be processed. If Essential Information on a prior authorization request is missing, incorrect, or illegible, a decision to approve or deny cannot be made. We will return the request to the requesting provider with an explanation of why the submitted request was not processed as submitted and include instruction to resubmit the prior authorization request with complete Essential Information. A complete request form includes the following Essential Information:
  • Member Name
  • Member Number
  • Member Date of Birth
  • Ordering Provider
  • Service Provider Name
  • National Provider Identifier (NPI)
  • Tax Identification Number (TIN)
  • Date of Service
  • Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS)
  • Quantity of service units requested based on the CPT, HCPCS, or CDT requested.

Complete Authorization Requests

An authorization request must include all information/documents required to make and establish a medical or functional necessity determination. Utilization Management staff receive current clinical via fax, phone, or confidential voice mail from the requesting provider, attending physician, facility personnel or access to a facility-specific electronic medical record. In addition, online requests for outpatient prior authorization require clinical information attachment prior to submission. In order to apply the appropriate medical policy and make a decision, the following clinical information from the past 12 months (but not limited to) must be submitted:
  • Office and hospital records
  • A history of the presenting problem
  • A history of previous medical management
  • Physical exam results
  • Diagnostic testing results
  • Treatment plans and progress notes and prognosis
  • Patient psychosocial history
  • Information on consultations with the treating practitioner
  • Evaluations from other health care practitioners and providers
  • Operative and pathological reports
  • Rehabilitation evaluations
  • Patient characteristics and information
  • Information from responsible family members or caregivers
  • Community resources for discharge planning and follow up care
  • Any other information deemed necessary to facilitate the decision-making process.
In addition to the above, the following information is collected specific to behavioral health authorizations:
  • Level of functioning, including an ability to perform activities of daily living
  • Presence of suicidal or homicidal ideations
  • Mental status assessment; and
  • Participation in the milieu.

Incomplete or Insufficient Documentation

The following process applies when the FirstCare Health Plans receives a request for prior authorization for a Medicaid member under age 21, and the request does not contain complete documentation and/or information:
  1. FirstCare Health Plans returns the request to the Medicaid provider with a letter describing the documentation that needs to be submitted, and when possible, FirstCare Health Plans will contact the Medicaid provider by telephone and obtain the information necessary to complete the prior authorization process. 
  2. If the clinical information is not provided within sixteen (16) business hours of FirstCare Health Plans’ request to the Medicaid provider, FirstCare Health Plans sends a letter to the member explaining that the request cannot be acted upon until the documentation/information is provided, along with a copy of the letter sent to the Medicaid provider describing the clinical information that needs to be submitted. 
  3. If the clinical information is not provided to FirstCare Health Plans within seven calendar days (7) of its letter to the member, FirstCare Health Plans sends a notice to the member informing the member of its denial of the requested service due to the incomplete documentation/information, and providing the member an opportunity to request an appeal through FirstCare Health Plans’ internal appeals process and the HHSC fair hearing process.

Prior Authorization Timelines

  • STAR & CHIP
    • Within three Business Days after receipt of the request for authorization services;
    • Within one Business Day for concurrent Hospitalization decisions; and
    • Within one hour for post-hospitalization or life-threatening conditions, except that for Emergency Medical Conditions and Emergency Behavioral Health Conditions, prior authorization is not required.
  • STAR (Pharmacy Prior Authorization Timelines)
    • If the prescriber’s office calls the MCO’s PA call center, the MCO must provide prior authorization approval or denial immediately. 
    • For all other PA requests, the MCO must notify the prescriber’s office of a PA denial or approval no later than 24 hours after receipt. 
    • If the MCO cannot provide a response to the PA request within 24 hours after receipt or the prescriber is not available to make a PA request because it is after the prescriber’s office hours and the dispensing pharmacist determines it is an emergency situation, the MCO must allow the pharmacy to dispense a 72-hour supply of the drug.
  • Self-Insured
  • Commercial
  • Marketplace
  • Medicare D-SNP

Annual Prior Authorization Approval and Denial Rates

Statistics regarding Prior Authorization approval and denial rates for requested services.
  • Each list includes statistics on: 
    • Prior authorizations approved
    • Prior authorizations denied
    • Adverse determinations overturned on internal appeal
    • Total number of prior authorizations

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