This tip sheet outlines Community First Health Plans, Inc. and Community First Insurance Plan (Community First) requirements for identifying, applying, and maintaining preauthorization exemptions, including correct claim submission procedures and documentation expectations. It provides guidance to help physicians and providers ensure compliance and avoid potential payment reductions or denials.
What is a prior authorization exemption?
An exemption allows a qualifying provider to submit claims without obtaining prior authorization for specific health care services that normally require approval.
Are exemptions granted for all services?
No. Exemptions apply only to specific procedure codes listed in the exemption notice and are not global.
Who is the exemption tied to?
Exemptions are granted at the provider’s National Provider Identifier (NPI) level and are not transferable.
When does an exemption take effect?
On the date Community First issues the written exemption notice.
Which plans are included?
University Community Care Plan and Commercial Health Maintenance Organization (HMO) products.
How does a provider qualify?
Qualification is based on historical prior authorization approval rates for specific services during a defined review period.
How are claims submitted?
Claims may be submitted without an approved prior authorization for exempted services; all other billing and documentation rules apply.
Ordering/Referring vs. Rendering providers
Rendering providers may rely on an exempt ordering provider only if the ordering provider’s name and NPI are submitted on the claim.
Where is ordering/referring provider info listed?
CMS form 1500 (17, 17B), UB-04 (76–79), or corresponding 837 electronic fields.
Can providers share exemptions?
No. Except for the ordering scenario, providers may not rely on another provider’s exemption.
Supervised providers (NPs/PAs)
May rely on a supervising physician’s exemption when services are ordered under the physician’s NPI.
How are exemptions monitored?
Community First conducts periodic random claim reviews to ensure documentation supports medical necessity.
Can exemptions be rescinded?
Yes. Exemptions may be modified or rescinded if compliance or documentation requirements are not met.
Do exemptions change member benefits?
No. Exemptions do not alter coverage, benefits, or medical necessity standards.
Where can I find more information?
Texas Department of Insurance FAQ: https://www.tdi.texas.gov/health/hb3459-faq.html