House Bill 3459 Preauthorization Exemption Program
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Describes Ambetter Georgia's implementation of Texas House Bill 3459 allowing certain providers to be exempt from prior authorization for specific services, procedures, or drugs when they meet performance thresholds; applies to Ambetter programs (excluding Medicare/Medicaid) and is limited to Texas Ambetter Health providers for consideration.
No material clinical or coverage changes in this revision.
Exemption Eligibility & Retention
Exemption eligibility and retention
Covered when ALL of the following are met:
ALL of the following
- Provider must have a medical necessity approval rate of at least 90% for the specific service during the review period.
- Provider must have submitted at least 5 prior authorization requests for the specific service/procedure code or prescription during the review period.
- Exemption retention is subject to periodic rescission review in January and June; Ambetter will review a sample of between 5 and 20 medical records for claims received.
- Exemption may be rescinded if 90% of the sampled records do not meet medical necessity criteria following clinical review.
Exempted Codes, Thresholds, and Volume Requirements
| Exemption is applied at the service/procedure code or prescription level as listed on the provider's notification letter; ordering provider NPI/name must be present on rendering provider claim when applicable to avoid prior authorization being required. For paper claims: include ordering provider name and NPI in fields 17 and 17B of the CMS Form 1500 and in fields 78-79 of the CMS Form 1450 (UB-04). For electronic claims: include the information in the corresponding fields of the ASC X12N 837 format. If this information is not included, the claim will be subject to applicable prior authorization requirements. |
Operational Rules, Notifications, Appeals, and Impact on Referrals
Waiver applied at claims adjudication; include ordering provider NPI on claims
Prior authorization is waived for listed exempt procedural/service codes; Ambetter's claims system is configured to automatically waive prior authorization for applicable exempt codes. If a provider submits an authorization request for an exempt code, the provider will receive a faxback indicating no authorization is required. When an ordering provider is different from the rendering provider, the ordering provider's name and NPI must be included on the rendering provider's claim (fields 17 and 17B on CMS 1500, fields 78–79 on CMS 1450/UB‑04, or corresponding electronic ASC X12N 837 fields) to avoid the claim being subject to prior authorization requirements.
- Claims system automatically waives prior authorization for applicable exempt codes.
- Faxback will be sent if an authorization is submitted for an exempt code indicating no authorization is required.
- Ordering provider name and NPI must appear on rendering provider claim (CMS 1500 fields 17/17B; CMS 1450 fields 78–79; or ASC X12N 837 equivalents) when applicable.
Appeal exemption denials and rescissions to Ambetter; IRO and TDI options
Providers may appeal Ambetter's initial exemption denial or a rescission decision by submitting documentation and the notice letter to Ambetter Appeals via fax or mail; for rescission decisions providers may also request an independent review (IRO) or file a complaint with the Texas Department of Insurance (TDI).
- Submit documentation plus the denial letter to Ambetter Appeals via fax or mail to appeal an initial exemption denial.
- For rescission appeals, providers may request an independent review from an IRO or file a complaint with TDI.
Choose mail or email for exemption notifications
Providers choose how they receive exemption notifications—via mail or email—by completing Ambetter's online communication preference survey.
- Complete Ambetter's online communication preference survey to select mail or email notification.
Referrals, benefit limits, and eligibility still apply despite exemption
Exemption from prior authorization does not remove other administrative or benefit controls: Value/Virtual providers must still file referrals for specialists, DME, or home health, and benefit limits and member eligibility continue to apply.
- Value/Virtual providers must continue to submit referrals for specialists, Durable Medical Equipment (DME), and home health.
- Benefit limits are not waived and member eligibility still governs payment.
- Referral requirements are considered separate from the Preauthorization Exemption Program.
Scope, Program Applicability, and Ineligible Services
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