Reminder - Notice of Prior Authorization Exemptions Renewal Review


As we indicated on May 30, 2023, BCBSTX has reviewed existing PA exemptions that were effective 10/1/2022 for particular health care services and determined if the PA Exemption can be renewed. For each particular health care service under review, BCBSTX randomly selected at least 5 claims processed after 10/1/2022 and requested medical records for this review. If at least 90% were medically necessary, then the PA exemption will be renewed for that particular health care service.  

Renewal Status Communication

After completion of the claim review, if the provider did not meet the 90% threshold, they will be sent a notice, under the TAX ID that billed the claims indicating the PA exemption was rescinded. The rescission notice 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).

Please note: To protect the privacy of our members, if a provider has more than one TAX ID, the other Tax IDs will receive a copy of the rescission notice that does not include claim data. The provider must refer to the other notice for claim and IRO information.  

The rescission PA exemption notices for these reviews will be available via the BCBSTX- branded Availity® Payer Spaces in the Prior Authorization Exemption Viewer by June 30. Any providers who submitted an alternate preference for HB3459 notifications (email or mail) by April 19, 2023, will also receive their notification by their preferred communication method. If the provider met the 90% threshold, the PA Exemption will be maintained, and a courtesy notice will be available in July in Availity or sent by the providers preferred communication method.

For more information, refer to the Prior Authorizations Exemptions page on the provider website. 

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.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.