Prior Authorization Exemptions (Texas House Bill 3459)

Under Texas House Bill 3459, providers may qualify for an exemption from submitting prior authorization requests for specific health care service(s) no later than Oct. 1, 2022, for all fully insured (TDI is indicated on the ID card) and certain Administrative Services Only (ASO) groups.

Exemption Status Communications

Blue Cross and Blue Shield of Texas (BCBSTX) is reviewing required prior authorizations submitted from Jan 1 – June 30, 2022. Providers who submitted at least 5 required prior authorization reviews for applicable members will be 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 will be issued for the applicable particular health care service(s). 

The easiest way to view your PA Exemption Status communications will be via 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 by Oct. 1, 2022.

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 submitted a request by Sept. 14, 2022 your initial prior authorization exemption status communication will be delivered by your preferred method.  Any requests received after Sept. 14 will be used for future communications. In addition, all initial prior authorization status communications will be available via Availity. 

After reviewing your PA Exemption Status communication, if you have a general inquiry or you would like to request an appeal of a denied exemption for a particular health care service, forms will be available here on or before Oct. 1, 2022 to submit your request.

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

Refer to the lists of services that require prior authorization on the Utilization Management page and code lists applicable to the exempted care categories.

Re-evaluation of Prior Authorization Exemption Status

Your exemption will last 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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