PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Prior Authorization
Prior authorization is the utilization review processes to decide whether the requested service, procedure,
medication or medical device meets clinical criteria for coverage. Prior authorization is not a guarantee of
payment for care or services given to members. The prior authorization process requires the collection of
information before inpatient admissions, performance of ambulatory procedures or delivery of selected services
in order to:
• Permit verification of eligibility and benefits
• Provide a chance for communication with the doctor and/or the member
• Coordinate the patient’s transition across the continuum of care
• Help in the identification of members eligible for special programs
A Primary Care Provider must complete the Texas Referral/ Authorization Form for all services on the Parkland
Prior Authorization list except for the following:
• Submit all DME requests on the Title XIX form
• Submit all initial outpatient therapy requests utilizing the TP1 form
• Submit TP1 (request for initial outpatient therapy) or TP2 (request for extension of outpatient therapy).
The completed form (Appendix D) should be faxed to the Medical Management Department at the number
listed in the Important Numbers (see page 1 of this manual).
Notification regarding newborn and sonogram process
The authorization process for newborn delivery/admission and sonograms is as follows:
Newborn admission/delivery B process:
• Authorization must be requested for any newborn after day 4 of stay
• DRG hospitals must meet the acute LOC level of care
• A prepayment review will be conducted on all DRG 790's
• All others will be paid - with random audits conducted periodically.
Sonogram process:
• CHIP Perinate -– Members can get one sonogram per pregnancy. For additional procedures, there must be a high- risk
diagnosis along with supporting clinical documentation. Information must be submitted and approved prior to the 2nd
sonogram being performed. Complete the Texas Referral Authorization Form and fax to 1-800-240-0410.
OB process:
• No authorization is required for OB global days (2-day uncomplicated delivery & 4-day uncomplicated C-section).
• Anything outside of the OB global must be authorized.
• If the DRG is a higher DRG upon submission of claim, must follow the current appeal process for any denied claims.
Contact your provider relations representative or call 1-888-672-2277 with questions about these changes.
Claims for Obstetric Deliveries to Require a Modifier
Claims that are submitted for obstetric delivery procedure codes 59409, 59410, 59514, 59515, 59612, 59614,
59620, or 59622 will require one of the following modifiers:
97
Modifier
To Indicate