Community Health Choice, Prior Authorization

Community Health Choice, prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Community Health Choice states that prior authorization is required for non-emergent services when the plan requires it, and that authorization does not guarantee payment. The provider page includes plan-specific guidance. For Medicaid/STAR+PLUS, routine prospective UM determinations are shown as within 3 business days in one section and 7 calendar days in another section of the same page, so that variation should be preserved. For Medicare, urgent determinations are within 72 hours, routine within 7 calendar days, and inpatient within 24 hours. For pharmacy, urgent requests are immediate if the prescriber calls, routine requests are answered within 24 hours, and a 72-hour supply may be allowed if Community cannot respond in time or the prescriber is unavailable after-hours. Retrospective review determinations are stated as within 30 calendar days after receipt of the request, with fax submission required.
• The provider prior authorization page repeats plan-specific sections and contains internally inconsistent timeframes across sections; the response preserves those differences instead of choosing one.
• Authorization does not guarantee payment.
• Failure to obtain required prior authorization may result in claim denial or administrative denial, depending on the section/plan described.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3

How to submit prior authorization requests

• Fax

• Phone

• Provider Portal / web submission where plan-specific forms are offered

• Mail / paper forms where applicable

• Submission resource 1

• Submission resource 2

• Submission resource 3

Information commonly required

• Member name
• Member date of birth
• Member Medicaid/CHIP identification number
• Requesting provider name and NPI
• Servicing provider name and NPI
• Requested service
• Requested CPT codes
• Number of units requested
• Dates of service
• In-network requesting provider signature
• Supporting clinical documentation to validate medical necessity

Turnaround notes and caveats

• Medicaid/STAR+PLUS page shows prospective review timeframes that vary within the page: one section states urgent no later than 3 business days and routine within 3 business days; other sections state urgent no later than 72 hours, routine within 7 calendar days, and inpatient within 24 hours.
• Medicare prior authorization guidance states urgent as soon as possible and no later than 72 hours, routine within 7 calendar days, and inpatient within 24 hours.
• Retrospective review determinations are stated as within 30 calendar days from receipt of the request.
• The provider prior authorization page repeats plan-specific sections and contains internally inconsistent timeframes across sections; the response preserves those differences instead of choosing one.
• Authorization does not guarantee payment.
• Failure to obtain required prior authorization may result in claim denial or administrative denial, depending on the section/plan described.

Provider resources

• Provider Home (official)
• Resources (official)
• Forms and Guides (official)
• Prior Authorization Information (official)
• HIPAA / Electronic Claims (Marketplace) (official)
• Contact Community (official)
• Provider Claims Billing Guidelines (Jan 2026) (official)

Sources