Texas Auth guidelines

If patient has a Medicaid plan that is a Family Planning program, they will need to be self pay.   These plans are available in ALL states.  So when running Simplicity, you need to look at the plan name (See example below). If plan name comes up as FP | Limited to family planning services, please let patient know that they need to be self pay and change insurance to self pay according to the state you are scheduling in.

Auth requirements:

Health Choice/Health Choice Generations: OB US is 5-7 days TAT, DUPLEX/DOPPLER is 5-7 day minimum TAT

Tricare: All US, MG, BD, MRI & CT require auth- 14 days minimum TAT

Alignment: US- 7 days minimum TAT

Optum: MRI, NM, PET, CTA, MRA is 14 days minimum TAT (In Nevada ONLY: Out of network for all PET, NM & US except ABI, Arterial, Venous mapping and Prostate and out of network for ALL CT except CT lung, CTA for PE, CTA runoff and patients over 400 lbs.  

Mercy Care/Mercy Care Advantage: US (Elastrography) cpt 76981 is a 14 day minimum TAT

Scan Health: ALL Breast Imaging - 7 day minimum TAT

Humana: All CT/A, MRI/A, NM Modalities are 5-7 days.

Humana FL (Only) All modalities - Schedule 9 days out.  Add-Ons ONLY allowed if patient has referral/authorization number on hand.

COMMONLY MISCHEDULED PROCEDURES

PLEASE NOTE:  WE ARE CONTRACTED WITH AMBETTER SUPERIOR HEALTH PLAN AND VALUE HEALTH NETWORK IN TEXAS. 

WE ARE CONTRACTED WITH AMBETTER TX BRONZE, SILVER, GOLD, SELECT & VIRTUAL 

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