CurrentOptumPolicy N/A

Texas Medicaid Behavioral Health Authorization Service Request Form

A fax-based authorization request form to be used by providers for behavioral health facility-based care (inpatient, residential detox, PHP, IOP, residential treatment, ECT) under Texas Medicaid; includes required clinical documentation fields and instructions for initial, concurrent, and discharge reviews. Not a medical coverage policy.

Policy Summary

PayerOptum

PolicyTexas Medicaid Behavioral Health Authorization Service Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

Key ActionProviders must fax the completed Texas Medicaid Behavioral Health Authorization Service Request form with required clinical documentation (limit attachments to 4-8 pages) to 844-280-1168; fax court orders to 888-821-5101 when applicable.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is a standardized administrative authorization form (has_material_change=false).

844-280-1168Fax number for submission

888-821-5101Court order fax number

4-8 pagesAllowed attachment length

Behavioral healthForm use

Document Summary

This is the Texas Medicaid Behavioral Health Authorization Service Request — a fax-based administrative form used by providers to request authorization for behavioral health facility-based services (including inpatient mental health, residential detox/ASAM 3.7, residential treatment, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), SUD ASAM levels, and outpatient Electroconvulsive Therapy (ECT)). It is used for initial, concurrent/extension, and discharge reviews and collects administrative identifiers, clinical information, and specialized sections (e.g., ASAM assessment for SUD and ECT-specific data). This document is an administrative authorization/service request form for submission and not a medical coverage policy.

Metadata

PayerOptum

Policy TitleTexas Medicaid Behavioral Health Authorization Service Request Form

Policy NumberN/A

StatusCURRENT

Scope SummaryA fax-based authorization request form to be used by providers for behavioral health facility-based care (inpatient, residential detox, PHP, IOP, residential treatment, ECT) under Texas Medicaid; includes required clinical documentation fields and instructions for initial, concurrent, and discharge reviews. Not a medical coverage policy.

Allowed attachment length4-8 pages

Fax number for submission844-280-1168

Court order fax number888-821-5101

Who / What This Form Applies To

Scope & Applicability

Scope SummaryProviders use this fax-based form for behavioral health facility-based care under Texas Medicaid, capturing administrative and clinical data for initial, concurrent, and discharge reviews.

ApplicabilityUsed by providers for Texas Medicaid behavioral health facility-based care (do not use for medical prior authorization).

Covered levels of care collected on formInpatient Mental Health; Residential Detox Sub-Acute (ASAM 3.7); Residential Treatment; Partial Hospitalization Program (PHP); Intensive Outpatient Program (IOP); Outpatient Electroconvulsive Therapy (ECT); SUD ASAM 3.5 and ASAM 3.7; Other (with code fields).

Use Conditions

Form use conditions and submission requirements

Use this form for behavioral health facility based care only (do not use for medical prior authorization).

Protect PHI and follow HIPAA guidelines.

Include only medically necessary documentation and limit additional documentation to 4-8 pages; attach only requested items.

Fax the completed form to 844-280-1168.

If on a court order, fax court order to 888-821-5101.

Request Types and Required Form Data

Submission Types and Required Data

Form sections required depending on request type

Request Type (choose one)

Initial Request — provide requesting facility information for initial only.
Concurrent/Extension — include authorization number and last covered day for concurrent reviews.
Urgent — if urgent, include clinical reason.

Patient / Facility Identifiers

Member first and last name, DOB, Medicaid ID.
Legal guardian name & phone if applicable.
PCP phone and fax.
Requesting and Servicing Facility Tax ID and NPI, addresses and phone/fax.
Admission date, requested start date, expected discharge date.

Level of Care Selection

Selectable levels: Inpatient Mental Health (voluntary/involuntary), Residential Detox Sub-Acute (ASAM 3.7), Residential Treatment, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), Outpatient ECT, SUD ASAM 3.5/3.7, or Other.

Level of Care / Procedure Code fields (form collects these)mixed

ASAM 3.7	Residential Detox Sub-Acute Detox (non-hospital setting)
ASAM 3.5	SUD ASAM 3.5
ASAM 3.7 WM	ASAM 3.7 WM (check box available)

Required Clinical Documentation to Fax

Clinical Documentation Requirements

Minimum documentation to include with faxed request

Complete all relevant inpatient, detoxification, residential treatment, PHP, or IOP sections.

If SUD, submit complete ASAM Assessment (all ASAM dimensions included on form).

Include current medication list.

Do not fax extraneous or old chart documents.

Documentation Required

Fax completed authorization form

Providers must fax the completed Texas Medicaid Behavioral Health Authorization Service Request form with required clinical documentation. Limit additional documentation to 4-8 pages and attach only what is requested. Fax the completed form to 844-280-1168. If the member is on a court order, fax the court order to 888-821-5101.

Documentation Required

Include ASAM assessment for SUD

For members with a primary substance use disorder diagnosis, submit a complete ASAM Assessment covering ASAM Dimensions 1 through 6 with the authorization request.

ASAM Dimension 1: Acute intoxication or withdrawal potential
ASAM Dimension 2: Biomedical conditions and complications
ASAM Dimension 3: Emotional, behavioral, or cognitive conditions and complications
ASAM Dimension 4: Readiness to change
ASAM Dimension 5: Relapse, continued use or continued problem potential
ASAM Dimension 6: Recovery and living environment

ECT and Cognitive-Impairment Submission Requirements

ECT and Cognitive Diagnosis Additional Requirements

Extra data elements required for ECT or cognitive impairment/age ≥65

Indicate if member is child/adolescent, pregnant, or has presence of dementia.

Document medical clearance and relevant medication exposures (steroids, digoxin, sinemet, benzodiazepines, antihistamines).

Provide seizure duration in seconds and whether seizure considered adequate; include historical cognitive testing/baseline, results of cognitive tests and dates (e.g., MMSE, MoCA).

Provide prior ECT treatment dates and results, medication trial failures, transport/monitoring plan, discharge plan and outpatient ECT access; include abnormal labs if present (e.g., BUN, WBC, urine leukocyte).

Documentation Required

Provide ECT-specific clinical data

For ECT requests include seizure duration (in seconds) and whether the seizure was considered adequate; provide historical cognitive testing or baseline with test results and dates (e.g., MMSE, MoCA); list prior ECT treatment dates and results; include relevant medication history and any prior medication trial failures; and document transport and monitoring plans and whether the member is medically cleared.

Discharge Review Requirements

Document precipitant and circumstances that led to admission and additional event details.

State whether substance use contributed and provide details.

List current acute symptoms, psychosocial stressors, and functional impairments.

Provide primary and secondary DSM-5 diagnoses with codes and active medical conditions.

Include discharge plan (including level of care), barriers to discharge, follow-up appointment information and provider contact, and member location after discharge.

For inpatient mental health discharges, follow-up appointment must be within 7 days.

Documentation Required

Timely discharge follow-up

For inpatient mental health discharges, document a follow-up appointment scheduled within 7 days after discharge to meet the discharge review requirement.

Policy Summary

PayerOptum

PolicyTexas Medicaid Behavioral Health Authorization Service Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

On This Page

OpenPayer

Texas Medicaid Behavioral Health Authorization Service Request Form

Document Summary

Who / What This Form Applies To

Request Types and Required Form Data

Required Clinical Documentation to Fax

ECT and Cognitive-Impairment Submission Requirements

Discharge Review Requirements

Definitions

Document Changes