How to Complete and Submit a BCBS of Texas Prior Authorization Form

The Blue Cross Blue Shield of Texas prior authorization form is the Texas Standard Prior Authorization Request Form for Health Care Services (form number NOFR001), a state-mandated document that every Texas health insurer must accept in the same format under Texas Insurance Code Chapter 1217.¹ Your provider’s office usually fills it out and submits it, but knowing what belongs on each line, how it moves through the system, and when a decision is due helps you catch problems before they turn into denials.

Where to Get the Form

The NOFR001 form is available as a downloadable PDF on the BCBS of Texas provider website under the forms section of the Education and Reference Center.² Providers can also reach it through Availity, the electronic portal BCBS of Texas uses for authorization submissions.³ As a patient you generally won’t complete the form yourself, but pulling a copy lets you see exactly what your clinician needs from you.

Completing the Six Sections

The standardized form has six sections, and incomplete or mismatched information is the leading reason submissions come back for rework instead of being reviewed.⁴

Section I: Submission Information

Enter “Blue Cross and Blue Shield of Texas” as the issuer, along with the applicable phone and fax numbers and the submission date. BCBS of Texas uses different fax lines for different plan types, so sending to the wrong number delays processing.

Section II: General Information

Mark the request as urgent or non-urgent, and indicate whether it is an initial request or an extension, renewal, or amendment. Urgent requests require a written clinical explanation of why delay could seriously harm the patient. If you’re extending an existing approval, the previous authorization number belongs here.

Section III: Patient Information

Enter the patient’s name, date of birth, gender, phone, and the Member or Medicaid ID number printed on the insurance card. When the subscriber is a different person than the patient, the subscriber’s name goes in this section too, along with the group number. A single wrong digit in the member ID triggers an automatic rejection before any human reviewer sees the file.

Section IV: Provider Information

Two providers may appear here: the requesting provider and the service provider who will actually perform the procedure. Each needs a name, NPI number, specialty, phone, and fax. HMO plan members also need their primary care provider named, because HMO plans route most specialist services through a PCP referral.⁵ Some submissions require the requesting provider’s signature and date at the bottom of this section.

Section V: Services Requested and Supporting Diagnoses

This is the clinical core. Enter the CPT, CDT, or HCPCS code for the planned procedure, its start and end dates, and the ICD diagnosis code that justifies it. Specify the setting: inpatient, outpatient, provider office, observation, home, day surgery, or other. Additional subsections capture details for particular service types:

Therapy services (physical, occupational, speech, cardiac rehab, or mental health and substance abuse) require the number of sessions, duration, and frequency.
Home health requires confirmation that a physician-signed order and nursing assessment are attached, plus number of visits, duration, and frequency.
Durable medical equipment requires a physician-signed order, an equipment or supplies description with HCPCS codes, and duration of need.

The diagnosis code must match the procedure code logically. An ICD code for knee osteoarthritis paired with a CPT code for a shoulder MRI will draw a rejection, not a phone call for clarification.⁴

Section VI: Clinical Documentation

Attach the supporting evidence: lab results, imaging reports, pathology findings, office visit notes, and records of previous treatment failures that show why the requested service is necessary. For specialty drugs, include documentation of any step therapy protocols already tried. The more complete the clinical picture at first submission, the less likely BCBS of Texas will request additional information, which resets the review clock.

How to Submit the Form

BCBS of Texas accepts submissions electronically and by fax or mail. The electronic route is faster and creates a trackable record immediately.

Through Availity

Most providers submit through Availity, which sends a HIPAA-standard 278 transaction to BCBS of Texas.³ The steps:

Log in to Availity.
Select Patient Registration, then Authorizations & Referrals, then Authorizations.
Select BCBSTX as the payer and choose your organization.
Select Inpatient Authorization or Outpatient Authorization.
Review the details and submit.

The portal returns a confirmation number and lets providers upload clinical records, check status, and edit or extend existing authorizations.⁶

By Fax or Mail

Paper submission is still available. Print the completed form, attach all supporting clinical documentation, and fax or mail it to the BCBS of Texas medical management department. Predetermination of benefits requests, where a provider wants to confirm coverage before scheduling a non-urgent procedure, are submitted by fax or mail using the Predetermination Request Form along with relevant medical records.⁶ Fax numbers vary by plan type and appear on the member’s insurance card and in the BCBS of Texas provider manual.

Which Services Require the Form

BCBS of Texas publishes separate prior authorization services lists for fully insured groups and ASO (administrative services only) groups, both updated effective January 1, 2026.⁷ Codes shift periodically, but the categories that consistently require prior authorization include:

Inpatient hospital admissions, including many continued stays beyond an initial approved period.
Outpatient surgeries, particularly complex procedures like joint replacements and spinal fusions.
Advanced imaging: MRI, CT, PET scans, and nuclear medicine studies.
Specialty pharmacy drugs, including biologics for rheumatoid arthritis, multiple sclerosis, and cancer.
Behavioral health services: inpatient psychiatric care, residential substance abuse treatment, and intensive outpatient programs.
Durable medical equipment such as power wheelchairs, pressure-reducing support surfaces, prosthetics, and orthotics.
Home health and therapy services, including skilled nursing visits, physical therapy beyond initial evaluations, and cardiac rehabilitation.

Organ transplants and certain genetic tests also appear on these lists.⁸ Because the specific list varies by plan, providers should verify requirements for every patient encounter through Availity before rendering services.⁹

How Long a Decision Takes

For standard requests, BCBS of Texas must send its determination no later than the second working day after both receiving the request and having all the information needed to review it.¹⁰ The clock does not start until the file is complete, so a missing document effectively pauses the timeline.

When the insurer denies a request, the notification deadlines tighten based on the patient’s situation:

Hospitalized patient: notification to the provider by phone or electronic transmission within one working day, followed by a written letter to the provider and patient within three working days.
Non-hospitalized patient: written notice to the provider and patient within three working days.
Post-stabilization care after emergency treatment: notification to the treating provider within one hour of the request.

For concurrent reviews of ongoing prescription drugs or IV infusions, the insurer must provide at least 30 days’ notice before discontinuing coverage.

When the Form Isn’t Required: Gold Card Exemptions

Texas law offers a shortcut for providers with strong approval records. Under the state’s gold card program, a physician or provider qualifies for an exemption from prior authorization for a particular service if at least 90 percent of their prior authorization requests for that service were approved during the most recent 12-month evaluation period, and they submitted at least five eligible requests.¹¹

Providers do not apply. Each insurer must evaluate its providers at least annually and issue notices of exemption or denial. The exemption is tied to the provider’s NPI number and extends to care ordered or referred by the exempt provider regardless of who performs the service. Starting September 1, 2025, under HB 3812, insurers must count all prior authorization requests submitted across every health plan they issue or administer when evaluating a provider, not just requests under plans subject to the gold card statute.¹¹ If your provider holds a gold card for the service you need, the form isn’t required and treatment proceeds without the usual waiting period. Ask before your appointment.

If the Request Is Denied

BCBS of Texas must explain why a request was denied and describe your appeal rights in the denial notice.¹²

Internal Appeal

You or your provider can appeal directly with BCBS of Texas. The denial notice explains how to file and the deadline; missing that window forfeits your right to challenge the decision. Appeals can be filed in writing, by phone, or by fax. For denials involving emergency care, continued hospitalization, or life-threatening conditions, you can request an expedited appeal, which the insurer must decide within 72 hours.¹³

Peer-to-Peer Review

Your treating physician can request a peer-to-peer conversation with the insurer’s medical director. This is often the most effective step because it puts the physician who examined you in direct contact with the physician who reviewed the paperwork. The provider of record can request this specialty review within 10 working days of the appeal request or denial.¹³

External Review

If the internal appeal doesn’t resolve the denial, you can request an external review by an independent reviewer who does not work for BCBS of Texas or your provider. File the request in writing within four months of receiving the final internal denial notice. External review is available when the denial involves medical judgment, when a treatment is deemed experimental, or when coverage was canceled based on alleged misinformation in your application. Standard external reviews must be decided within 45 days, and expedited reviews for urgent medical situations within 72 hours. The cost to you is either nothing or a maximum of $25. The insurer is legally required to accept the reviewer’s decision.¹⁴

Emergency Care Does Not Require Prior Authorization

Prior authorization rules do not apply to genuine emergencies. Under the No Surprises Act, your health plan cannot deny coverage because you did not get prior authorization before going to the emergency room.¹⁵ Even if the emergency treatment is delivered by an out-of-network facility or physician, you owe only your in-network cost-sharing. If BCBS of Texas or an emergency provider bills you for more than your in-network share after emergency treatment, that is a billing error worth disputing.

1
State of Texas. Texas Insurance Code Chapter 1217 – Standard Request Form for Prior Authorization of Health Care
2
Blue Cross and Blue Shield of Texas. Blue Cross and Blue Shield of Texas Health Care Provider Forms
3
Blue Cross and Blue Shield of Texas. Availity Authorizations and Referrals
4
Blue Cross and Blue Shield of Texas. Texas Standard Prior Authorization Request Form for Health Care Services
5
Blue Cross and Blue Shield of Texas. Blue Essentials
6
Blue Cross and Blue Shield of Texas. New Prior Authorization and Referral Submission Tool via Availity Provider Portal
7
Blue Cross and Blue Shield of Texas. Prior Authorization Services For Fully Insured and ASO
8
Blue Cross and Blue Shield of Texas. BCBSTX’s Prior Authorization Process
9
Blue Cross and Blue Shield of Texas. How to Request Prior Authorization
10
State of Texas. Texas Insurance Code 4201.302 – General Time for Response
11
Texas Department of Insurance. FAQ on Preauthorization Exemptions
12
Texas Department of Insurance. How to File an Appeal or Ask for an External Review
13
Blue Cross and Blue Shield of Texas. Complaints and Appeals
14
HealthCare.gov. External Review
15
U.S. Department of Labor. Avoid Surprise Healthcare Expenses – How the No Surprises Act Can Protect You