Updated Texas Clinical Prior Authorization Criteria Guides Released

Aug 25, 2025

1 minute

Updated Texas Clinical Prior Authorization Criteria Guides Released

The Texas Health and Human Services Commission (HHSC) has completed a review and update of several clinical prior authorization criteria guides.

Managed care organizations (MCOs) are responsible for incorporating these updates into their respective lists of clinical prior authorizations.

The Pharmacy Clinical Prior Authorization Assistance Chart provides a comparison of each MCO’s prior authorizations with those used to process fee-for-service Medicaid claims. This chart is updated on a quarterly basis.

Providers may use the MCO search tool to access links to each MCO’s list of clinical prior authorizations.

HHSC will issue notifications to pharmacies whenever updated prior authorization criteria are implemented for Medicaid fee-for-service.

Comments or questions may be directed to vdp-formulary@hhsc.state.tx.us.

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Credentialing is the rigorous process of verifying a healthcare provider’s qualifications, including their education, training, licenses, and clinical experience. This service ensures that practitioners meet the high standards required by insurance networks and hospitals to provide care and receive reimbursement.

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Billing and Collection service involves confirming a patient’s insurance coverage, active status, and specific benefits before their appointment. By identifying co-pays, deductibles, and required prior authorizations upfront, staff can prevent claim denials and help patients understand their financial responsibilities.

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Eligibility verification is the process of verifying a patient’s health insurance coverage and benefits to determine what services are covered and the level of coverage available. This process is essential for healthcare providers to ensure that they receive proper reimbursement for services rendered and that patients are not left with unexpected medical bills.

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RCM is the financial process that manages the entire lifecycle of a patient’s account, from the initial appointment scheduling to the final balance payment. It integrates eligibility, coding, billing, and collections into a single, cohesive workflow aimed at maximizing a practice's profitability.

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