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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
The Prior Authorization Reconsideration Request Form is required to initiate a request for reconsideration of a previously denied prior authorization. The form provides a brief description of the steps for reconsideration and is only for patients enrolled in Medicaid fee-for-service.
- The prescribing provider may request reconsideration only if the Texas Prior Authorization Call Center has denied a previous authorization request. An initial authorization request is not accepted with this request.
- Verify whether patient is enrolled in either Medicaid fee-for-service or a Medicaid managed care organization (MCO).
- If patient is enrolled with an MCO, refer to the Prescriber Assistance chart (PDF) to identify the appropriate pharmacy prior authorization and member call center phone number. Prior authorization processes and call centers are different for each MCO.
- To request reconsideration, supporting documentation may be included along with this request. Supporting documentation may include:
- Medication documentation, such as the patient's medical records or lab results that support the medical reason for the treatment.
- Peer-reviewed literature supporting the safety, efficacy and rationale for using the medication outside the current Texas Medicaid criteria, if applicable.
- Failure to include justification for medical necessity may result in reconsideration request denial.
- A healthcare professional will evaluate the request and will notify the prescribing provider in writing, of the prior authorization decision within five (5) business days. Both the requesting provider and patient will receive determinations of the request by mail.
- Fax: 866-617-8864
- Phone: Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927), Monday - Friday, 7:30 a.m. to 6:30 p.m. (central time)