09/01/2023 Updated 09/20/2023
Important Update – see updates below to Accessing your PA Exemption Status Communication
It is time again to review providers for prior authorization (PA) exemptions per Texas House Bill 3459. For providers that met the necessary criteria, Prior Authorization (PA) exemptions for particular service(s) were reviewed for Jan.1 – June 30, 2023 and providers that met the approval threshold are being issued a PA Exemption effective Sept. 1, 2023. This includes services for PA’s managed by BCBSTX Medical Management, Kelsey-Seybold, Carelon Medical Benefits Management, Inc. (CarelonTM) 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) are handled and conveyed by the PBM.
Evaluation of PA Exemptions
As a reminder, if you had at least 5 eligible PA’s for a particular service from Jan.1 – June 30, 2023 and received approval for at least 90% of them, the PA exemption will be satisfied for that service.
Accessing your PA Exemption Status Communication
As of 09/07/2023, view your PA Exemption Status communications via the Provider Correspondence Viewer (PCV) on 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 Provider Correspondence Viewer page on our website as well as New Location in Availity® to Access Prior Authorization Exemption Communications as of Sept.7, 2023 on News and Updates for more information.
Please note beginning with the 09/01/2023 PA Exemption notices, it will only include PA Exemptions you were reviewed for in this cycle. Refer to your previous notifications for other PA exemptions you may still qualify for. You can find all notifications in PCV.
As required by the Texas Department of Insurance regulation, if you submitted a request for another preferred communication method by July 31, 2023 (email or postal mail), to receive your PA Exemption notifications, your Sept. 1, 2023, notification will be sent by your preferred method. If received after that date, your request will be used for future communications.
Request Notification Acknowledgements for PA Exemption Services
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.
Please Note:
- 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 found on the Prior Authorization Exemption page.
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.
More Information
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 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.