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The document is the Texas Standard Prior Authorization Request Form for Health Care Services, mandated by the Texas Department of Insurance. It outlines the process for requesting prior authorization from health benefit plan issuers, including Medicaid and CHIP, effective September 1, 2015. The form must be sent to the issuer and not to state agencies or employers. It specifies what the form should be used for, details on urgent reviews, and requirements for clinical documentation. Additionally, it provides sections for patient and provider information, service requests, and necessary codes.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (284 Votes)
2015	4.9 Satisfied (36 Votes)

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