Cigna STAR+PLUS maintains a separate process for Prior Authorization depending on whether the provider is requesting Acute Care Services, Behavioral Health Services, or Community-Based Long-Term Care Services. Click the type of service to review Prior Authorization guidelines for services requested.
Prior Authorization Process
The Health and Human Services Commission (HHSC) has instructed STAR+PLUS managed care organizations to be more flexible in timelines for authorization determinations when insufficient, missing, or inaccurate information is received for a prior authorization request.
The information required to initiate the Prior Authorization review process, as defined by HHSC:
- Member name
- Member number or Medicaid number
- Member date of birth
- Requesting provider name
- Requesting provider’s National Provider Identifier (NPI) / TIN
- Rendering provider name
- Rendering provider’s National Provider Identifier (NPI) / TIN
- Service requested: Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
All Information Needed Received
- Turnaround time 3 business days
Information Insufficient, Missing, or Inaccurate
- Standard turnaround time may be extended
- If turnaround time is extended, the provider and member are notified
- Provider is given 3 additional business days to send in information requested
- If no additional information is received, the request is sent to the medical director to review the request
- Medical director has 3 more business days to review
- Final determination is sent to the provider and member no later than the tenth business day after the request was received
- Given holidays and weekends, the maximum amount of time given for review will not exceed 14 calendar days
The start of care date as defined by HHSC is the date that care is to begin as listed on the Prior Authorization request form.
Peer to peer consultations are available during this review process.
Pharmacy and non-emergency authorization requests are excluded from this process of extended timelines.