Prior Authorization Exemptions

Wellpoint will evaluate care providers annually to determine if they qualify for exempt status for a specific healthcare service. Care providers who submitted at least five requests will be assessed to ensure that at least 90% of those requests were approved. If they meet this criterion, they will receive an exemption for that specific healthcare service.

You have the right to appeal an exemption eligibility determination. An appeal form with instructions will be enclosed with your eligibility determination letter. The appeal request and completed form must be emailed to TXPriorAuthExemptionAppeals@wellpoint.com within 30 days of the determination letter's issuance date. 

 Texas HB 3459 Provider Preauthorization Exemption Appeal Form

Wellpoint will assess claims to verify if you still qualify for a previously granted exemption. Your exemption is valid for a minimum of 12 months and may be re-evaluated afterward. During this review, at least five randomly selected claims submitted will be evaluated for medical necessity criteria.

• If 90% of the claims are approved, your exemption will continue and may be reassessed in the future.
• If the approval threshold is below 90%, you will receive a rescission notice with a list of the claims selected for this evaluation.

If you receive a recession notice, you may request a review by an Independent Review Organization (IRO). The Texas Department of Insurance (TDI) will assign the IRO, who will make a decision within 30 days.

For more on this process, contact TDI at 866-554-4926, option 2, or MCQA@TDI.Texas.gov. You may also review the details that were included in your rescission notification. All requests must be made before the rescission effective date.

If no IRO appeal is filed following a rescission, prior authorization will be necessary for all relevant services from the rescission effective date. Exemptions that are rescinded will be reviewed again in six months to determine if reinstatement is possible.

A prior authorization exemption does not override benefits or eligibility requirements. Before providing services, verify a member’s benefits and eligibility via Availity Essentials, your electronic vendor, or by calling the number on the back of the member’s ID card.

Information for initial length of stay, service units, or frequency parameters for services with a prior authorization exemption can be found on our Prior Authorization page.

Note: Requests for additional days or units beyond the initial notification require an extension request or concurrent review and may need a medical necessity assessment.