09/01/2024
Blue Cross and Blue Shield of Texas has reviewed providers for prior authorization exemptions per Texas House Bill 3459 for the Jan. 1 - June 30, 2024 review period.
Evaluation of PA Exemptions
As with previous review cycles, providers that had at least 5 eligible PA’s for a particular service and met the 90% approval threshold are being issued a PA exemption effective Sept 1, 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 groups.
Note: PA exemption status for any prior authorization managed by a Pharmacy Benefit Manager are handled and conveyed by the PBM.
Accessing your PA Exemption Status Communication
Refer to the Provider Correspondence Viewer in the secure Payor Spaces section of the Availity® website to view notices issued effective Sept. 1. If you are not currently registered for Availity, sign up at no charge on Availity Essentials or by contacting Availity Client Services at 1-800-282-4548. Refer to our Prior Authorizations Exemptions page for a user guide on how to access your exemption via PCV. If you submitted a request, prior to Aug. 1, 2024, for mail or email for your PA exemption notifications, it will also be sent per your preferred method.
Reminder About Submitting 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.
Concurrent review is still required for ongoing or an extension of services beyond care guidelines.
A list of PA exempted services or codes applicable to your PA exemption care category as indicated on your notification are available on the TX HB3459 Elective Prior Authorization (PA) Exemption Clinical Guidelines found on then Prior Authorization Exemption page.
Questions or Appeals
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.