What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. Texas-only details below.
Confirm plan type: Texas: Start Here.
Texas PA rules
Texas regulates utilization review and prior authorization primarily through Insurance Code Chapter 4201 (utilization review agents) and related insurance laws. These rules generally apply to TDI-regulated health plans—not Medicare, typical self-funded ERISA plans, or many federal programs.
Gold carding / PA exemptions (Subchapter N, § 4201.653)
HB 3459 (2021), amended by HB 3812 (effective September 1, 2025), requires insurers and HMOs to evaluate providers at least once per year:
- If a physician or provider had ≥90% PA approval (or would-have-approved) for a specific service during the most recent 12-month evaluation period and provided the service at least 5 times, the plan may not require PA for that service from that provider
- Providers do not have to request the exemption—it can be applied automatically
- Exemptions may be rescinded only in January (after the first anniversary of the evaluation period) or under limited retrospective-review rules (§ 4201.655)
TDI FAQ: Preauthorization exemptions FAQ
Adverse determination notices (§ 4201.304)
- Non-hospitalized patients: written notice to patient and provider within 3 working days
- Hospitalized patients: telephone/electronic notice within 1 working day, written follow-up within 3 working days
- Post-stabilization denials: notice to treating provider within 1 hour of the request
- Concurrent Rx/IV discontinuation: at least 30 days advance notice before stopping covered drugs or infusions you are already receiving
Prescription drugs & step therapy
- Denials of formulary exceptions and step therapy exception requests are adverse determinations with expedited appeal rights (Insurance Code Ch. 1369 and § 4201.357)
- Many Rx/IV denials allow immediate IRO review without exhausting internal appeal (§ 4201.3601)
Federal deadlines (many Marketplace and group plans)
Federally regulated plans often follow CMS timing: 72 hours for urgent PA and 7 calendar days for standard requests—check your plan documents.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first.
Carrier links: Texas prior auth & internal appeals links.
Medicaid
Texas Medicaid managed care (STAR, STAR+PLUS, STAR Kids, etc.) follows HHSC and MCO utilization management rules. Service denials use the MCO appeal and state fair hearing process—not commercial gold-carding under § 4201.653.
If PA is denied
Appeal the adverse determination through your plan's utilization review appeal process (Ch. 4201, Subchapter K), then independent review if needed.
Next: Texas internal appeals.
Urgent care
Expedited UR appeals for emergency care, continued hospitalization, and many Rx/IV disputes must be resolved within 1 working day after all necessary information is received (§ 4201.357)—not later than medically appropriate.
Life-threatening conditions may qualify for immediate IRO review without internal appeal (§ 4201.360).