Texas Pre Authorization Request Form – Fill Out and Use This PDF

Texas Pre Authorization Request Form is a form created by the Texas Department of Insurance.

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Texas Pre Authorization Request Form PDF Details

The Texas pre authorization request form is a document used to request prior authorization for coverage of medical services. The form can be used by healthcare providers, patients, or caregivers to request coverage for services that may not be covered under a patient's insurance plan. The form must be completed and submitted to the insurer before the service is provided in order to determine if the service is covered under the insurance plan. The Texas pre authorization request form can be found on the website of the Texas Department of Insurance (TDI). The TDI website provides instructions on how to complete and submit the form, as well as a list of required information that must be included in the request.

Here is some data that may be useful if you're looking to find out just how long it'll take you to complete texas pre authorization request form and how many PDF pages it includes.

Question	Answer
Form Name	Texas Pre Authorization Request Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	14
Avg. time to fill out	3 min 3 sec
Other names	amerigroup authorization form texas, amerigroup prior authorization form texas, amerigroup prior authorization form, texas amerigroup inpatient authorization fax form

12

Form Preview Example

Prior Authorization Form for Texas Medicaid

Global Prescription Exceptions (Medicaid)

This fax machine is located in a secure location as required by HIPAA regulations.

Complete/review information, sign and date. Fax signed forms to Caremark at 1‐866‐255‐7569.

Please contact Caremark at 1‐877‐440‐3621 with questions regarding the prior authorization process.

When conditions are met, we will authorize the coverage of Global Prescription Exceptions.

Drug Name:

Patient Name:

Patient ID:

Patient Group Number: Patient Date of Birth:

Physician Name:

Physician Phone:

Physician Fax:

Physician Address: City, State ZIP:

Patient Information

Prescribing Physician

Diagnosis:

ICD Code:

Please circle the appropriate answer for each question.

1.	If this is an office‐administered injectable drug…
	A. Is your intent to provide and bill for this medication? OR	Y	N
	B. Is your intent to have it provided through a pharmacy?	Y	N
		Y	N

2.	Is the requested drug being used for an FDA‐approved indication?	Y	N
	[If the answer to this question is yes, then skip to Question 4.]

3.Is the requested drug being used for an indication that is supported by information from

	the appropriate compendia of current literature (e.g., AHFS, Micromedex, current	Y	N
	accepted guidelines, etc.)?

	4. Has the patient demonstrated a failure of or intolerance to a majority (not more than three)	Y	N
	of the preferred formulary or preferred drug list alternatives for the given diagnosis?	Y	N

5.Is the drug being prescribed within the manufacturer's published dosing guidelines, or

	does it fall within dosing guidelines found in the compendia of current literature (e.g.,	Y	N
	package insert, AHFS, Micromedex, current accepted guidelines, etc.)?

	6. Is the drug being prescribed for a medically accepted indication that is recognized as a	Y	N
	covered benefit by the applicable health plan's program?	Y	N
	covered benefit by the applicable health plan's program?

Comments:

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (or authorized) Signature and Date

PF‐TX‐0003‐12

March 2012

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