Prior Authorization Information

Information about Prior Authorization processing timeframes and Incomplete Prior Authorization Requests can be located in the Prior Authorization Requirements document linked below. For more information, please see the Provider Manual.

Prior Authorization timelines

Medicaid routine/non-urgent: 3 business days
CHIP routine/non-urgent: 2 business days (approval), 3 business days (adverse determination)
Concurrent hospitalization: 1 business day
Post-hospitalization or life-threatening conditions (except emergency medical or behavioral health conditions): 1 hour

Pharmacy
By phone: Immediate approval or denial
Medicaid: 24 hours
Emergency supply: 72-hour supply

Incomplete prior authorization requests:
If the prior authorization documentation is incomplete or inadequate, the reviewer is unable to process the request. In such instances, Dell Children’s Health Plan will notify the provider and member in writing no later than 3 business days after the prior authorization request received date to submit the additional documentation necessary to make a decision. Dell Children’s Health Plan will send the notice to the member based on their preferred method for receiving prior authorization request notices. If the member does not choose a preferred method, Dell Children’s Health Plan will mail the notice to the member.

The written request for additional information will include the following information:

  • A statement that Dell Children’s Health Plan has reviewed the prior authorization request and is unable to make a decision about the requested services without the submission of additional information.
  • A clear and specific list and description of the incomplete documentation/information that must be submitted in order to consider the request complete.
  • An applicable timeline for the provider to submit the missing information.
  • Information on the manner through which a provider may contact Dell Children’s Health Plan.

Dell Children’s Health Plan may also contact the provider by phone to obtain the information necessary to resolve the incomplete request.

Final determination of the prior authorization request will be completed within three business days after the date the missing information is provided. The SOC date will be honored when the provider is able to submit a complete request within the timelines discussed in this section and in the Determination Timelines section of this document, and Dell Children’s Health Plan has determined that the requested services meet medical necessity.

If no additional information is received by the end of the third business day from the date Dell Children’s Health Plan sent the notice to the provider and the prior authorization request will result in an adverse determination, Dell Children’s Health Plan will refer the request for medical director review with all information received with the request no later than seven business days after the prior authorization request received date. The Dell Children’s Health Plan medical director will make a determination based on the information previously received within three business days of the referral but no later than the tenth business day after the prior authorization request received date. If a holiday will result in the process exceeding 14 calendar days, Dell Children’s Health Plan will adjust the timeline accordingly to not exceed 14 calendar days to make a determination for the prior authorization request.

Additionally, if the request does not meet criteria for approval, the requesting provider will be afforded the opportunity to discuss the case with the medical director prior to issuing the denial.

Member assistance with prior authorizations

Members who have questions regarding prior authorizations may contact Member Services at 1-855-921-6284 (TTY 711), available Monday through Friday from 8 a.m. to 6 p.m. Central time.