Prior Authorization Exemptions                      (Texas House Bill 3459)

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.

Exemption Status 

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.

For the July-Dec. 2022 review period, if you submit a Prior Authorization Exemption Communication Preference Questionnaire by Feb. 6, 2023, your prior authorization exemption status communication will be  delivered by your preferred method.  Any requests received after Feb. 6 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 prior authorization status communications will be available via Availity. 

Prior Authorization Questions

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 InquiriesIn 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.

If you no longer meet the criteria to be exempted, you will be notified and will need to request prior authorization for all services when required. You will be able to appeal a denied exemption. Watch for more information in News and Updates on the provider website. 

Related Links

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