What is a Prior Authorization Exemption
Blue Cross and Blue Shield of Texas (BCBSTX) has been working on implementing Texas House Bill 3459 - Prior Authorization (PA) Exemptions which allows providers that meet the necessary criteria, PA exemptions for particular service(s). This includes services for PA’s managed by BCBSTX Medical Management, Kelsey-Seybold, AIM Specialty Health® or Magellan for fully insured and certain Administrative Services Only (ASO) groups.
Note: PA exemption status for any prior authorization managed by a Pharmacy Benefit Manager (PBM) will be handled and conveyed by the PBM.
Initial Evaluation of Prior Authorization Exemptions
Your prior authorization history based on your Type I National Provider Identified (NPI) including all Tax ID numbers you may bill under, has been reviewed from Jan. 1 through June 30, 2022. If you had at least 5 eligible PA’s for a particular service and received approval for at least 90% of them, the PA exemption will be satisfied for that service.
Communication of Prior Authorization Exemption Status
Since many providers are Availity® users, we will be making all notifications available in the secure Payor Spaces section of the Availity website. If you not currently registered for Availity, you can do so at no charge on Availity® Essentials or by contacting Availity Client Services at 1-800-282-4548 to get access. This will be the easiest and quickest method to access your PA exemptions. Watch for information coming soon on how to access your exemption via Availity.
As required by the Texas Department of Insurance regulation, if you prefer another method (email or postal mail), to comply with addressing it for your initial PA exemption status communication on or before October 1, 2022, you must submit it by 09/14/2022 using the Prior Authorization Exemption Communication Method Preference Questionnaire.
If you have qualified for a PA exemption, you should submit a Notification to BCBSTX to determine the initial length of stay or initial units exempted for service(s). Notification to BCBSTX is required, and services beyond the initial length of stay or units covered by the PA exemption may be reviewed for medical necessity. Notification can be submitted via Availity® Authorizations & Referrals, or by calling the number on the member’s ID card. A Notification Acknowledgement for the specific service(s) allowable per the prior authorization exemption will be provided.
- Concurrent review is still required for ongoing or an extension of services beyond care guidelines. Refer to the PA requirements list for criteria information.
- Providers will still need to check eligibility and benefits via Availity or your preferred vendor.
- Prior authorization is still required for all other services without a PA Exemption.
- Recommended Clinical Reviews are not required prior authorizations. These reviews are optional and provide notice of an adverse determination and opportunity to appeal if the Recommended Clinical Review determines the proposed service does not meet medical necessity. Refer to the Recommended Clinical Review page for a list of services.
- Recommended Clinical Reviews are not considered when a provider’s required prior authorization approval rating is calculated.
Important Claims Information
- Claims for services billed when prior authorization exemption applies will not be reviewed for medical necessity; however, ongoing or an extension of services beyond the prior authorization exemption are subject to concurrent medical necessity review.
- Rendering providers need to provide the NPI for attending, referring or ordering providers in Box 17 and 17B of the HCFA 1500 and in Box 76-79 on UB-04 or the equivalent fields on electronic claims in order for the facility to be considered under the attending, referring or ordering provider’s exemption.
Please refer to Prior Authorization Exemptions on our Utilization Management page and watch News and Updates for additional information.
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.
Blue Cross and Blue Shield of Texas contracts with Magellan Behavioral Health, Inc. (“Magellan”), an independent company, to administer BCBSTX’s managed mental health program.
AIM Specialty Health is an independent medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas (BCBSTX).
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.