Prior Authorizations

Certain medical services for MAP and MAP Basic patients are subject to preauthorization (PA) to ensure that care is provided by our contracted network clinicians and service providers and meets the minimum medical necessity standards. This prior authorization may come from Seton Health Plan or Central Health.

Central Health has a dedicated physician-led Utilization Management (UM) department that includes a UM nurse and a Program Coordinator.

Please note that all requests for services must include a completed PA form and pertinent medical records that are no older than 6 months.

Services Managed by Central Health

Below are some examples of services requiring prior authorization. This is not a comprehensive list, and providers should refer to their contract to determine if a prior authorization is necessary.

A) Elective (non-urgent) procedures/services scheduled at network ambulatory surgery centers or other facilities, for example:

• Certain ankle surgeries, foot surgeries, and ophthalmologic procedures
• Certain radiation therapies
• Certain oral and maxillofacial procedures
• Certain sleep studies and attended split-night polysomnography

B) Requests for certain Durable Medical Equipment (DME)

• CPAP and supplies
• Certain orthotics and prosthetics
• Wheelchairs
• Any other DME not listed in the provider contract

Central Health’s UM Department is responsible for a timely review of these requests and communication about approval or denial of these services. All requests for services must be made via email or fax. The Program Coordinator of our UM department is responsible for the initial receipt of the requests and provides all communication about the status of such requests. The UM nurse working closely with the medical director is responsible for determining the medical necessity of each service against established medical standards and the scope of coverage listed in the provider’s contract. While the nurse and medical director can approve services, all denials are reviewed by the medical director before a denial decision and next steps are communicated to the requesting provider.

Find below the turn-around time for services managed by Central Health:

• Urgent Requests – Three (3) Business Days
• Standard Requests – Ten (10) Business Days

For additional information and questions regarding preauthorization’s, please contact our UM department during normal business hours either by email or phone at:

• Email: Priorauthrequests@centralhealth.net
• Fax: 512-776-0485
• Phone: 512-978-8130 Option 3
  • Note: Real-time authorization status updates are not available through the phone number; however, information will be collected and a response provided by the UM team via email.

Services Managed by Seton Health Plan

Seton Health Plan reviews prior authorization requests for the MAP and MAP Basic healthcare services related to Seton provided inpatient care or other arranged healthcare services. MAP Basic healthcare services are provided pursuant to Seton Charity Care policies.

• For a listing of service/CPT codes that are managed by Seton Health Plan (SHP) please review the MAP Prior Authorization Grid posted on SHP’s website: https://insurance.ascension.org/tx-charity
• For the details about Seton Health Plan’s PA processes and scope of coverage for MAP and MAP Basic programs, please visit the following link – https://insurance.ascension.org/tx-charity

The Seton Health Plan has available peer to peer for adverse determinations. The attending provider may contact the SHP medical director that made the initial determination to discuss the services under review. The attending provider is notified within three (3) business days of the reconsideration decision.

Helpful Resources

Central Health Prior Authorization Form – Prior Authorization form

MAP – https://www.centralhealth.net/map/

Note: If requesting an authorization for a medication that is not on the formulary, submit a NonFormulary Drug Request (NFDR). Information regarding Non-Formulary Drug Request authorizations can be found here: https://www.centralhealth.net/medical-access-program-provider/non-formulary-medication-request/