Blue Cross and Blue Shield of Texas (BCBSTX) reviewed providers for prior authorization exemptions per per Texas House Bill 3459 for July 1-Dec. 31, 2022. For providers that met the necessary criteria, Prior Authorization (PA) exemptions for particular service(s) were issued effective March 1, 2023. This includes services for PA’s managed by BCBSTX Medical Management, Kelsey-Seybold, Carelon Medical Benefits Management, Inc. (CarelonTM) (formerly 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) were handled and conveyed by the PBM.
Evaluation of PA Exemptions
If you had at least 5 eligible PA’s for a particular service from July 1 – Dec. 31, 2022 and received approval for at least 90% of them, the PA exemption will be satisfied for that service.
Communication of PA Exemption Status
Once again we made 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 or by contacting Availity Client Services at 1-800-282-4548 to get access. This will be the easiest and quickiest method to access your PA exemptions. Refer to our Prior Authorizations Exemptions page for a user guide on how to access your exemption via Availity.
As required by the Texas Department of Insurance regulation, if you submitted a request before Feb. 6, 2023 for another preferred method, (email or postal mail), to receive your PA Exemption notifications, your March 1, 2022 notification was sent by your preferred method. If received after that date, your request will be used for future communications.
Reminder: Requesting Notification Acknowledgements
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® Essentials, 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 prior authorization services list for review criteria.
- 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.
A list of 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.
If you are a BCBSTX participating provider with a general inquiry regarding your PA exemption results, 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.
Please refer to Prior Authorization Exemptions on our Utilization Management page.
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.
Carelon Medical Benefits Management, Inc. (formerly AIM Specialty Health) is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.