July 1, 2025
We’ve reviewed prior authorization exemptions that were previously rescinded per Texas HB3459 for the Jan. 1 through June 30, 2025, review period to determine of the provider’s exemption can be reinstated. To view the results, refer to the Provider Correspondence Viewer in Availity® Essentials’ payer spaces for Blue Cross and Blue Shield of Texas. If you requested alternate methods for your prior authorization exemption communications, the results will be communicated through those channels.
Pharmacy exemptions: Prior authorization exemption status for any prior authorization managed by a pharmacy benefit manager is handled and conveyed by the PBM.
Evaluation of Prior Authorization Exemptions
If you had at least five eligible prior authorizations for a particular service during the review period, and received approval for at least 90% of them, the prior authorization exemption will be reinstated effective July 1, 2025. This includes services for prior authorization managed by BCBSTX Medical Management, Kelsey-Seybold, Carelon Medical Benefits Management or Magellan for fully insured and certain administrative services only groups.
Notification acknowledgements: If you have qualified for a prior authorization exemption, submit a notification to BCBSTX to determine the initial length of stay or initial units exempted for services. Services rendered beyond the initial length of stay or units covered by the exemption may be reviewed for medical necessity. Submit notification through Availity Essentials or by calling the number on the member’s ID card. You’ll receive a notification acknowledgement for the specific services allowable per the prior authorization exemption.
Questions on Exemption Results
If you have questions about your prior authorization exemption results, contact your local Network Management Representative for assistance. Non-participating providers can complete the Prior Authorization 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 Prior Authorization Exemption Appeal Form. Both forms can be emailed to TX PA Exemption Inquiries.
Refer to the Prior Authorization Exemptions page 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.