12/29/2023
BCBSTX providers that had a Prior Authorization (PA) Exemption for a particular service rescinded effective 07/01/2023 have recently been reviewed again to determine if they meet the criteria to reinstate their PA exemption.
Refer to “Accessing your PA Exemption Status Communication” below to see if your exemption was reinstated. Providers that met the approval threshold for the particular service are being issued a PA Exemption effective 01/01/2024. 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 during the review period and received approval for at least 90% of them, the PA exemption will be satisfied for that service.
Accessing your PA Exemption Status Communication
PA Exemption Status communications will be viewable via the Provider Correspondence Viewer (PCV) on our BCBSTX-branded Availity® Payer Spaces as of 12/31/2023. 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.
If you submitted a request to receive your PA Exemption notifications using another preferred communication method prior to Dec. 15. 2023 (email or postal mail), your notification will be sent by your preferred method. If received after that date, your request will be used for future communications.
Reminder - Request Notification Acknowledgements for PA Exemption Services
When you qualify 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.
Inquiries on PA Exemption Results
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.
Refer to the Prior Authorization Exemption page on the provider website 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.
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.