2024 BCBSTX Prior Authorization (PA) Exemption Communications Preference Questionnaire

As indicated in the Texas Department of Insurance’s HB3459 Prior Authorization (PA) Exemption regulation, providers can submit alternate methods for receiving their communications for HB3459. To submit your preference, complete the questionnaire below.

Note: The Prior Authorization Exemption page on the provider website will indicate a due date to submit the request in order to comply with periodic notifications of new Prior Authorization Exemptions. Refer to the website for pertinent dates. If we receive a request after a due date, it will be adhered to for future communications.

All fields are required unless otherwise indicated.

Submit one questionnaire per Tax ID. The preference requested will be applied to all providers under the Tax ID. If any providers within a Tax ID require a different communication method, you will need to submit a separate questionnaire for each provider.

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* 1. Tax ID Number

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* 2. Organization or Practice Name

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* 3. Organizational TYPE II NPI (if applicable)

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* 4. Individual Provider Name

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* 5. TYPE I NPI (if individual provider)

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* 6. Provider is a Behavioral Health provider.

Yes

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* 7. Contact Information for Person Completing Questionnaire

Name

Title

Phone Number

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* 8. Select preferred method for PA Exemption Communications

Availity® (www.availity.com)

Email (provide the preferred email address in Question 9)

Mailing Address (provide the preferred mailing address in Question 10)

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* 9. Email Address (if preferred method)
Note: BCBSTX is not responsible if the email address provided is no longer valid or blocks email from BCBSTX. If an email address is used and that person leaves the practice, providers are responsible for updating the PA Exemption Communications Preference Questionnaire.

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* 10. Mailing Address (if preferred method):

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Thank you for your cooperation,
Blue Cross and Blue Shield of Texas

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. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.