Texas Medicaid: Help avoid service delays

Submit any required medical necessity documentation with prior authorization requests

As you know, some prior authorization requests require clinical documentation to support a medical necessity determination. This documentation must be submitted along with the prior authorization form.

Supporting documentation requirements are based on clinical criteria in UnitedHealthcare medical policies and guidance from UnitedHealthcare physicians and pharmacists with experience in reviewing service requests for coverage. Additionally, some requirements for supporting documentation are determined by the Texas Health and Human Services Commission.

For example, supporting documentation is needed if a provider requests a magnetic resonance imaging (MRI) screening in an outpatient hospital. In those cases, a provider also is required to submit medical notes documenting:

• The patient’s recent history
• A physical examination, including patient weight
• Patient condition, allergy, chronic disease and surgical plan
• Other specific criteria (see coverage rationale) that qualifies the individual for the site of service requested

Resources

View the resources below for more information on which documentation is necessary for a prior authorization request.

• Medical Record Requirements for Pre-Service Reviews
• Medicaid Provider Manual
• UnitedHealthcare Community Plan Policies and Clinical Guidelines
• Training: View our Prior Authorization and Notification: Interactive User Guide

How to submit a request

You can submit a prior authorization request through the UnitedHealthcare Provider Portal:

• Go to UHCprovider.com and click Sign In at the top-right corner
• Enter your One Healthcare ID and password
  • New users who don’t have a One Healthcare ID: Visit UHCprovider.com/access to get started
• In the menu, select Prior Authorizations 
• Scroll down to “Create a new notification or prior authorization request” and select Create New Submissions
• Enter the required information and submit

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