Managed Care (Medicaid and CHIP)

Traditional Medicaid

Complete both forms.  Refer to form for requirements and submission instructions.Failure to submit both forms will result in authorization denial.Submit to the Texas Prior Authorization Call Center.

Form Name Form Number
Standard Prior Authorization Request (PDF) TDI NOFR002
Synagis Standard PA Addendum HHS 1321

CSHCN Services Program

Complete both forms.  Refer to form for requirements and submission instructions.Failure to submit both forms will result in authorization denial.Submit to the CSHCN Services Program.

Form Name Form Number
Standard Prior Authorization Request (PDF) TDI NOFR002
Synagis Standard PA Addendum HHS 1325