Prior Authorization Request

Texas Standard Prior Authorization Request Form for Health Care Services, submitted online.

  1. 1Request form/
  2. 2Review/
  3. 3Confirmation

Fill in the request, attach your clinical documents and submit. You will get a case reference number on screen as soon as we receive it. Fields marked with an asterisk are required.

Before you start

Have ready: the member ID, the requesting and servicing NPIs, the CPT or HCPCS and ICD-10 codes, and your clinical documents (PDF, JPG, PNG or DOCX).

Do not use this form to request an appeal, confirm eligibility, verify coverage, request a guarantee of payment, ask whether a service needs prior authorization, request prior authorization of a prescription drug, or request a referral to an out-of-network provider.

Prefer to fax? Download the PDF form, fill it in and fax it with your clinical documents to 1-325-603-0541.

Section I — Submission

Issuer Name

Evry Health

Phone

1-855-579-3879

Fax

1-325-603-0541

Date

 

Your contact information

Who should our clinical team contact about this request?

We'll email your case reference number here.

Section II — General Information
Review Type (required)

Urgent is for a life-threatening condition, a patient in the hospital now, care after an emergency is stabilized, or an acute injury or illness that could seriously worsen without a quick decision.

Request Type (required)
Section III — Patient Information
Sex
Section IV — Provider Information
Requesting Provider or Facility

An issuer needing more information may call the requesting provider directly at this number.

Service Provider or Facility
Primary Care Provider (if different)

Only if the patient’s plan requires a primary care provider and it is not the requesting provider.

Section V — Services Requested (with CPT or HCPCS code) and Supporting Diagnoses (with ICD code)

Enter each code first: its description fills in, and you can change it.

Procedures (CPT or HCPCS)

Up to 50. A code can be listed again, for example with different modifiers (LT and RT). End dates can be up to 180 days from today; units and up to 4 modifiers are optional.

  1. Procedure 1

Diagnoses (ICD-10)

Up to 50, each code once. Diagnoses support the whole request, not one procedure.

  1. Diagnosis 1

Type of Service (required)
Therapy
Section VI — Clinical Documentation

Summarize the clinical information supporting this request: a brief narrative of medical necessity, or attach it as a document below.

Supporting clinical documentation (required)

Medical records, progress notes, lab reports, letters of medical necessity. PDF, JPG, PNG or DOCX; up to 20 files, 25 MB each and 29 MB in total.

Attestation

Nothing is sent until you submit on the next step.