05/30/2023
Effective Oct. 1, 2022, Blue Cross and Blue Shield of Texas (BCBSTX) implemented Texas House Bill 3459 (HB3459) which allowed qualified providers an exemption from submitting prior authorization (PA) requests for specific health care service(s) for fully insured (TDI indicated on ID card) and certain Administrative Services Only (ASO) commercial members. These PA Exemptions are effective for at least 6 months.
Renewal of PA Exemptions
After 6 months, as per HB3459, BCBSTX can review existing PA exemptions for particular health care services and determine if the PA Exemption can be renewed. For each particular health care service under review, BCBSTX will randomly select at least 5 claims processed after 10/1/2022 and if at least 90% were medically necessary, then the PA exemption will be renewed for that particular health care service. BCBSTX will be requesting medical records for this PA Exemption review. Please be sure to promptly return the requested records.
Renewal Status Communication
At the completion of the claim review, the provider will be notified that the PA exemption either was maintained or has been rescinded. The rescission letter will indicate the effective date of the rescission, a list of the claims reviewed and results for each claim. It will also indicate the process the provider can pursue for appeal of the rescission by an Independent Review Organization (IRO).
PA Exemptions effective Oct.1, 2022 are currently being reviewed.. The maintain and rescission PA exemption renewal notices for these reviews will be available via the BCBSTX- branded Availity® Payer Spaces in the Prior Authorization Exemption Viewer in June 2023. Any providers who submitted an alternate preference for HB3459 notifications (email or mail) by April 19, 2023, will receive their notification by their preferred communication method.
For more information, refer to the Prior Authorizations Exemptions page on the provider website.