Prior Authorization 

The Utilization Management (UM) department will evaluate the request to assess the Medical Necessity and coverage of proposed treatment. CHRISTUS Health Plan will also check that the treatment is being provided at the appropriate level of care. Prior authorizations are approved or denied based on current evidence- based clinical standards of care and guidelines and not on incentives or bonus structures. The member and provider will receive notification of CHRISTUS Health Plan’s decision, whether approved or denied.

• View clinical criteria used by CHRISTUS Health Plan

Note: If the requirements for prior authorization are not followed, CHRISTUS Health Plan may not pay for the services. In most cases, physicians and other providers will be responsible for getting the prior authorization from the health plan. We have instructions and procedures in place for providers to request prior authorization.

Disclaimer: 

*PRIOR AUTHORIZATION DOES NOT GUARANTEE PAYMENT ON NON-COVERED BENEFIT.
**PRIOR AUTHORIZATION DOES NOT GUARANTEE COVERAGE OR ELIGIBILITY.

The Prior Authorization lists for each specific line of business is below. Please remove any previous versions of the Prior Authorization list from your reference materials.

Updates to the Prior Authorization List are in progress. USFHP Medical Injectables (J and Q codes) PA list is now available for review. Please continue to check this page for the most current information and upcoming changes.

US Family Health Plan (USFHP)

• USFHP Prior Authorization Form (PDF)

• US Family Health Plan (Prior Authorization List)
• USFHP Medical Injectables (J and Q Codes) (Prior Authorization List)

Individual and Family Plan

All Texas Individual & Family Health Exchange Plan providers should utilize the Texas Standard Prior Authorization Form for Health Care services and submit prior authorization requests via fax to 844-357-7562.

• Texas Health Insurance Exchange Prior Authorization Form (PDF)
• Louisiana Insurance Exchange Prior Authorization Form (PDF)
• Hemo Dialysis Transplant Evaluation and Transplant Form (PDF)

• Louisiana Health Individual and Family Plan (Prior Authorization List)
• Texas Health Individual and Family Plan (Prior Authorization List)

Medicare Advantage Plan

• Medicare Advantage Prior Authorization Form (PDF)

• New Mexico Medicare Advantage (Prior Authorization List)
• Texas Medicare Advantage (Prior Authorization List)

Nueces County Hospital District (NCHD)

Nueces County Hospital District (NCHD) providers should utilize the Texas Standard Prior Authorization Form for Health Care services and submit prior authorization requests via fax to 844-357-7562.

• Texas Health Insurance Exchange Prior Authorization Form (PDF)

• NCHD (Prior Authorization List)

Texas Health Exchange Authorization Reports

• Approval and Denials with Overturns
• Indications Offered by Provider Specialty

Contact Numbers

• Individual and Family Plan: for a (Texas and Louisiana) prior authorization inquiry, call: 844-282-3025, TTY 711.  Available Monday - Friday, 8 a.m. - 5 p.m., CST
• Medicare Advantage: for a Texas prior authorization inquiry, call: 844-282-3026, TTY 711. Available Monday - Friday, 8 a.m. - 5 p.m., CST
• Medicare Advantage: for a New Mexico prior authorization inquiry, call: 844-282-3026, TTY 711. Available Monday - Friday, 8 a.m. - 5 p.m., GMT
• US Family Health Plan: for a prior authorization inquiry, call: 800-446-1730, TTY 711.  Available Monday - Friday, 8 a.m. - 5 p.m., CST

For any other provider related inquiries, please call Member services at 844-282-3100.

---