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2015-04-16T14:00:10-05:00
2015-07-03T12:37:01-05:00
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Texas Standard Prior Authorization Request Form for Health Care Services - NOFR001
Texas Department of Insurance
Adobe PDF Library 11.0
prior authorization, health care, healthcare
D:20150416185751
Texas Department of Insurance
Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standard Prior Authorization Request Form for Health Care Services if the plan requires prior authorization of a health care service.
Use this form to request authorization by fax or mail when an issuer requires prior authorization of a health care service. An Issuer may also provide an electronic version of this form on its website that you can complete and submit electronically, through the issuer’s portal, to request prior authorization of a health care service.
Do not use this form to: 1) request an appeal; 2) confirm eligibility; 3) verify coverage; 4) request a guarantee of payment; 5) ask whether a service requires prior authorization; 6) request prior authorization of a prescription drug; or 7) request a referral to an out of network physician, facility or other health care provider.
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