Prior Authorization Exemptions (Texas HB3459)

Update on March 1, 2025: The prior authorization exemption notices for the review period of July 1 through Dec. 31, 2024, are now posted in the Provider Correspondence Viewer in Availity® Essentials’ payer spaces for Blue Cross and Blue Shield of Texas. Learn more

Prior Authorization Exemptions Summary

Under HB3459, providers may qualify for an exemption from submitting prior authorization requests for specific health care services for all fully insured and certain Administrative Services Only group members. Fully insured members have “TDI” on their member ID card.

Exemption Status 

We periodically review required prior authorization submissions to determine if providers qualify for any exemptions for specific services. We’ll also review claims to determine if the provider still meets the qualifications to keep a previously issued exemption.

During the applicable review period for new prior authorization exemptions, providers who submitted at least five required prior authorizations for applicable members are reviewed to determine if at least 90% of the reviewed requests were approved. If a provider meets these qualifications, a prior authorization exemption is issued for the particular health care service. Refer to Re-evaluation of Prior Authorization Exemption Status below for information on continuation of prior authorization exemptions after they are issued. 

Accessing Exemption Status Communications

You can view all of your prior authorization exemption communications via the Provider Correspondence Viewer in Availity’s payer spaces for Blue Cross and Blue Shield of Texas. If you are 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

Per the Texas Department of Insurance regulation, providers can complete the Prior Authorization Exemption Communication Preference Questionnaire to notify us of your preferred communication method.

  • If you complete a questionnaire at least 30 days prior to the distribution of any notifications, your prior authorization exemption status communication will be delivered by your preferred method.
  • Any requests received later will be used for future communications.
  • If you previously submitted a request and do not have any changes, we will continue to honor your specified preference.

In addition, all initial determination and renewal communications of prior authorization status will be available via Availity.

We are not responsible if the email address provided is no longer valid or blocks email from BCBSTX. If an email is used and that person leaves the practice, providers are responsible for updating the questionnaire.

Have a Question?

Contact your local Network Management Representative for assistance.

Non-participating providers can complete the PA Exemption Inquiry Form and email it back to us.

Appeals of Denied Exemptions

To submit an appeal of a denied TX HB3459 prior authorization exemption for a specific treatment setting or care category, complete the PA Exemption Appeal Form and email it back to us.

This form is only for appealing the results of TX HB3459 prior authorization exemption.

In addition, you can file a complaint with the Texas Department of Insurance.

Prior Authorization Exemption Process

  • Prior authorization exemption does not supersede benefits or eligibility requirements.
  • Prior to rendering services, please confirm benefits and eligibility through Availity or your preferred electronic vendor or by contacting BCBSTX. This process will also notify you if the service has an exemption for the member submitted.
  • Please submit a notification to determine the initial length of stay or initial units for services with a prior authorization exemption. Notification can be submitted via Availity Authorizations & ReferralsBlueApprovRSM or by calling the number on the member’s ID card. A notification acknowledgement for the specific services allowable per the exemption will be provided.
  • Any days or units beyond what is outlined in the notification acknowledgement will require submission of an extension request (or concurrent review) and may be subject to a medical necessity review. 
  • For members not covered per HB3459 by the prior authorization exemption, providers will need to continue to request the appropriate prior authorizations.
  • For ordering or referring providers who may not be submitting claims, claims submitted by the rendering or billing provider must include the referring provider in Box 17 and 17B of the HCFA 1500 and in Box 76-79 on UB-04 claims or the applicable field on electronic submission.

Services Applicable to Prior Authorization Exemption

Review the below list of the TX Prior Authorization Exemption Care Categories which require prior authorization for certain plans. In addition, we have the TX HB3459 Elective Prior Authorization Exemption Clinical Guidelines, which contain a list of the PA exempted services or codes applicable to the specific Care Categories as indicated on your notification. Providers should also refer to required prior authorization lists on the Utilization Management page.

List of TX Prior Authorization Exemption Care Categories - Effective Jan. 1, 2025, (Changed the name for Medical Transportation category)

List of TX Prior Authorization Exemption Care Categories - Effective through Dec. 31, 2024

Prior Authorization Exemption Clinical Guidelines

Re-evaluation of Prior Authorization Exemption Status

Your exemption will last at least six months and may be re-evaluated after that time to determine if you still meet the exemption requirement for the particular health care services or other qualifying care categories. We will review at least five randomly chosen claims submitted during the evaluation period against medical necessity criteria.

  • If the review meets the 90% approval threshold, your prior authorization exemption will continue and may be evaluated during a future evaluation period. 
  • If the 90% approval threshold is not met, you will be sent a rescission notice that includes a list of the claims reviewed. To protect the privacy of our members, this notice will be sent under the Tax ID that billed the claims. 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. 

You can request a review of your rescission conducted by an independent review organization not associated with BCBSTX. Refer to your notification for information on how to submit the request for an IRO review. The request can be submitted via fax to 1-972-907-1868 or mail to BCBSTX PO Box 660044 Dallas, TX 75266. It must be received before the rescission effective date on your notice. The Texas Department of Insurance will assign the IRO provider and the IRO will make a decision within 30 days of receipt of the request. For information about the independent review process, please contact TDI at 1-866-554-4926, option 2 or email MCQA@TDI.Texas.gov.

If a prior authorization exemption for a particular health service is rescinded, unless you request an appeal for an IRO, you will need to request prior authorization for all services when required as of the effective date of the rescission. If your exemption is rescinded, it will be reviewed again after six months to determine if it can be reinstated.

Related Links

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