Ambetter Preauthorization Exemption Program

Date: 10/03/22

In response to House Bill 3459, effective October 1, 2022, issuers have the right to grant, deny or rescind qualifying preferred providers from obtaining a preauthorization exemption for select health care services, procedure codes and/or prescription drugs.

Ambetter from Superior HealthPlan recognizes the high level of care providers deliver to our members. In accordance with this bill, participating providers who meet the regulatory criteria outlined below will be enrolled in Ambetter’s Preauthorization Exemption Program.

To qualify for the preauthorization exemption program, a provider must meet the following requirements listed below within the designated six-month examination period for the same health care service, procedure code and/or prescription drug. Providers must have:

• Submitted at least five preauthorization requests.
• Received at least 90% preauthorization approval rate.

Preauthorization history will be reviewed based on a provider’s National Provider Identifier (NPI), during a six-month evaluation period. The first evaluation period for review was for preauthorization requests submitted between January 1, 2022 – June 30, 2022. The second evaluation period is July 1, 2022 – December 31, 2022. Subsequent review periods will be January 1 – June 30 and July 1 – December 31 every year.

Providers who have qualified for an exemption will be notified via mail of the service(s), procedure code(s) and/or prescription(s) for which they are exempt. Providers who have not been notified of an exemption must continue to submit preauthorization requests.

Claims for services billed when exemption applies will not be reviewed for medical necessity; however, Ambetter will conduct a review of medical records twice a year and notify providers in January and June each year whether we will rescind or extend preauthorization exemption.

Please note:

• Concurrent Inpatient Review Services are excluded from preauthorization exemption.
• Providers will still need to verify member eligibility and benefits prior to rendering services.
• Preauthorization is still required for all other services without an exemption.

For more information, please visit the Texas Department of Insurance website at TDI.Texas.Gov/Health/HB3459.html

For questions, please contact your local Account Manager.

Please Note: Ambetter will notify providers regarding any updates to this notice, please make sure to check back under Ambetter Provider News for the latest information.