Prior Authorization Exemptions

Per Texas legislation, providers may qualify for an exemption from requesting prior authorizations for specific health care services. The exemptions are applicable to all fully insured and certain Administrative Services Only group members. Fully insured members have “TDI” on their member ID card.

Exemption Status 
Once a year, we review required prior authorization submissions to determine if providers qualify for  exemptions for specific services. We’ll also review claims to determine if the provider still meets the qualifications to keep a previously issued exemption.

For reviews of new prior authorization exemptions, providers who submitted at least five required prior authorizations 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 care category.  The exemption will be effective for at least one year and may then be re-evaluated.

If you had at least five prior authorizations, but you did not meet the 90% approval threshold to qualify for an exemption, you can request an independent external review by an independent review organization at no cost to you. Refer to Reviews by an IRO below. You can also file a complaint with the Texas Department of Insurance.

Accessing Exemption Status Communications
You can view all of your prior authorization exemption communications via the Provider Correspondence Viewer in Availity® Essentials 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 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 60 days prior to the distribution of any notifications, your prior authorization exemption 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.  You do not need to resubmit the request unless you are changing your preference.

We are not responsible if the email address or mailing provided is no longer valid or blocks email from BCBSTX.  If the email or mailing address are no longer valid, providers are responsible for updating the questionnaire.

All  prior authorization communications can be viewed in Availity regardless of communication preferences submitted..

Have a Question?
Contact your local Network Management Representative for assistance.

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

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.
  • You are encouraged to request a notification to BCBSTX for exempted services provided to applicable members to determine if it is covered under the benefit plan and confirm the initial length of stay or initial units covered by the exemption. Notifications can be submitted via Availity Authorizations & Referrals 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 covered by the prior authorization exemption or outlined in the notification acknowledgement will require submission of an extension request (or concurrent review) and may be subject to a medical necessity review. Note: The Clinical Guidelines below indicate the maximum days or # of units covered by the exemption. 
  • Providers will need to continue to request the appropriate prior authorizations for members not covered by the prior authorization exemption.
  • 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
The  BCBSTX Prior Authorization Exemption Care Categories  provides the care categories which may require prior authorization for certain plans.  Also refer to required prior authorization lists on the Utilization Management page.

List of BCBSTX Prior Authorization Exemption Care Categories - Effective August 29th, 2025

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

Prior Authorization Exemption Clinical Guidelines

Prior Authorization Exemption Renewal
Your exemption will last at least one year and may be re-evaluated to determine if you still meet the exemption requirement for the particular health care services/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 after one year. 
  • If the 90% approval threshold is not met, your  PA exemption will be rescinded effective the date on the rescission notice. The notice includes the list of the claims reviewed. To protect the privacy of our members, the claim numbers are deidentified. You can submit an inquiry to TX_PA_Exemption_Inquiries@bcbstx.com and include a copy of your notice to get the complete claim numbers. 

When your prior authorization is rescinded, you can request a review by an independent review organization by the date indicated in the notice. Refer to Reviews by an IRO below. Unless you request an IRO appeal, you will need to request prior authorization for all services when required as of the effective date of the rescission. Your exemption will be reviewed again after one year to determine if it can be reinstated.

Reviews by an IRO
When you qualify to be reviewed for a prior authorization exemption and it is denied or if your exemption is rescinded, you can request a review be conducted by an IRO not associated with BCBSTX. Refer to your notification for information including the IRO form and the timeframe to submit the IRO request. The request can be submitted via fax to 972-907-1868 or email to Gold_Card_Audit_TX_IRO@bcbstx.com. 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 866-554-4926, option 2 or email MCQA@TDI.Texas.gov.

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