Under Texas House Bill 3459 (HB3459), providers may qualify for an exemption from submitting prior authorization requests for specific health care service(s) for all fully insured (TDI is indicated on the ID card) and certain Administrative Services Only (ASO) groups.
Blue Cross and Blue Shield of Texas (BCBSTX) will periodically review required prior authorizations submitted to determine if providers qualify for any exemptions for specific services or review claims to determine if the provider still meets the qualifications to keep a previously issued exemption.
During the applicable review period for new PA Exemptions, providers who submitted at least 5 required prior authorizations for applicable members are reviewed to determine if least 90% of the reviewed requests were approved by BCBSTX. If a provider meets these qualifications a Prior Authorization (PA) Exemption is issued for the applicable particular health care service(s). Refer to Re-evaluation of Prior Authorization Exemption Status below for information on continuation of PA exemptions after they are issued.
Exemption Status Communications
The easiest way to view your PA Exemption Status communications is via the Prior Authorization Exemption Status Viewer on our BCBSTX-branded Availity® Payer Spaces. If you are currently not signed up for Availity, you can do so free of charge by registering at Availity or by contacting Availity Client Services at 1-800-282-4548. Refer to the Prior Authorization Exemption Status User Guide to learn how to view your exemption status notice online.
Per the Texas Department of Insurance (TDI) regulation, providers can complete the Prior Authorization Exemption Communication Preference Questionnaire to notify BCBSTX of your preferred communication method.
If you complete a Prior Authorization Exemption Communication Preference Questionnaire, your prior authorization exemption status communication will be delivered by your preferred method if received at least 30 days prior to the distribution of any notifications. Any requests received later will be used for future communications. If you previously, submitted a request and do not have any changes we will continue to honor your specified preference. In addition, all initial determination and renewal communications of prior authorization status will be available via Availity®.
Have a Question?
If you are a BCBSTX participating provider with a general inquiry, contact your local Network Management Representative for assistance. Non-participating providers can complete the PA Exemption Inquiry Form.
If you would like to request an appeal of a denied exemption for a specific treatment setting or care category, complete the PA Exemption Appeal Form.
Both forms can be emailed to TX PA Exemption Inquiries. In addition, you can also file a complaint with the Texas Department of Insurance (TDI).
Prior Authorization Exemption Process
- PA Exemption does not supersede benefits or eligibility requirements.
- Prior to rendering services, please confirm benefits and eligibility through Availity or your preferred electronic vendor or by contacting BCBSTX. This process will also notify you if the service has a PA exemption for the member submitted.
- We request you submit a notification to determine the initial length of stay or initial units for service(s) with a PA Exemption. Notification can be submitted via Availity® Authorizations & Referrals or by calling the number on the back of the member’s ID card. A Notification Acknowledgement for the specific service(s) allowable per the PA exemption will be provided.
- Any days/units beyond what is outlined in the Notification Acknowledgement will require submission of an extension request (or concurrent review) and may be subject to a medical necessity review.
- For members not covered per HB3459 by the PA exemption, providers will need to continue to request the appropriate prior authorizations.
- For ordering or referring physicians or providers who may not be submitting claims, claims submitted by the rendering or billing provider must include the referring provider in Box 17 and 17B of the HCFA 1500 and in Box 76-79 on UB-04 claims or the applicable field on electronic submission.
Services Applicable to Prior Authorization Exemption
A list of the PA exempted services or codes applicable to the Outpatient Care Categories or Inpatient Treatment/Types as indicated on your notification are available on the TX HB3459 Elective Prior Authorization (PA) Exemption Clinical Guidelines. In addition, refer to the lists of services that require prior authorization on the Utilization Management page.
Re-evaluation of Prior Authorization Exemption Status
Your exemption will last at least six months and may be re-evaluated at that time to determine if you still meet the exemption requirement for the particular health care service (s) and/or other qualifying care categories. We will review at least 5 randomly chosen claims submitted during the evaluation period against medical necessity criteria.
- If the review meets the 90% approval threshold, your PA exemption will continue and may be evaluated during a future evaluation period.
- If the 90% approval threshold is not met, you will be sent a notification of rescission which includes a list of the claims reviewed.
You can request a review of your rescission conducted by an Independent Review Organization (IRO) not associated with BCBSTX. Refer to your notification for information on how to submit the request for an IRO review. It must be received before the rescission effective date on your notice. The Texas Department of Insurance (TDI) will assign the IRO provider and the IRO will make a decision within 30 days of receipt of the request. For information about the independent review process, please contact TDI at 1-866-554-4926, option 2 or email MCQA@TDI.Texas.gov.
If a PA exemption for a particular health service is rescinded, unless you request an appeal for an IRO, you will need to request prior authorization for all services when required as of the effective date of the rescission.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.