Form 1322, Medicaid Fee-For-Service Prior Authorization Reconsideration Request

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Effective Date: 5/2024


Updated: 5/2024


The Medicaid Fee-For-Service Prior Authorization Reconsideration Request Form is required to initiate a request for reconsideration of a previously denied prior authorization. This form briefly describes the steps for reconsideration and is only for patients enrolled in Medicaid fee-for-service.

Detailed Instructions

  1. The prescribing provider may request a reconsideration only if the Texas Prior Authorization Call Center denied a previous authorization request.  An initial authorization request is not accepted with this request.
  2. Verify if the patient is enrolled in either Medicaid fee-for-service or managed care.
    • If the patient is enrolled in managed care, refer to the MCO Search to identify the managed care organization's pharmacy prior authorization and member call center phone numbers. Prior authorization processes and call centers are different for each MCO.
  3. To request a 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 supporting 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.
  4. Failure to include justification for medical necessity may result in an appeal request denial.
  5. A health care professional evaluates the request and notifies the prescribing provider in writing of the prior authorization decision within five business days. The requesting provider and patient will receive the determination of the request by mail.


  • Fax: 866-617-8864
  • Phone: Texas Prior Authorization Call Center at 877-728-3927 (877-PA-TEXAS), Monday - Friday, 7 a.m. to 7 p.m. (central time)