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BCBS TexasCommercial · Prior Auth · Prior Authorization · TX · Oncology, Radiology, Orthopedics +1 moreHigh impact

Prior Authorization Changes for Some Commercial and Government Program Members

Act
by Dec 31, 2025
Effective date
Jan 1, 2026
Identified
Jan 12, 2026

Summary

Blue Cross Blue Shield of Texas is implementing major changes to prior authorization requirements and review vendors for commercial and Medicare Advantage members. Multiple service categories including advanced imaging, musculoskeletal procedures, oncology, genetic testing, and specialty drugs will have new prior auth requirements or transfer to different review entities (BCBSTX, Carelon, or removal from EviCore).

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What to do

by Dec 31, 2025 · 4 steps
01Billing team must update prior authorization workflows for two implementation phases.
02Phase 1 (Jan 1, 2026): Medicare Advantage members - verify new review entities for specialty drugs, lab codes, musculoskeletal, medical oncology, genetic testing, and radiation therapy now reviewed by BCBSTX instead of EviCore.
03Phase 2 (April 1, 2026): Commercial members - update prior auth requirements for advanced imaging, musculoskeletal, sleep, genetic lab, and medical oncology codes now reviewed by Carelon; Medicare Advantage adds DME codes to BCBSTX review.
04Always verify current prior auth requirements through Availity Essentials before service delivery.
If missed: Failure to obtain required prior authorization may result in claim denials with no patient billing allowed.

Original notice

Prior Authorization Changes for Some Commercial and Government Program Members
bcbstx.com · Always check the source before changing claims.
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Related changes

See all BCBS Texas changes →
Prior Authorization Changes for Some Commercial and Government Program MembersHighEffective Oct 1, 2026 · Prior AuthorizationFAQ Update: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026HighEffective Jan 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial and Government Program MembersHighNo effective date · Prior AuthorizationPrior Authorization Changes for Some MembersHighEffective Oct 1, 2026 · Prior AuthorizationBrowse every BCBS Texas change in the policy list

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BCBS Texas policiesTX policy changesOncologyRadiologyOrthopedicsSleep Medicine

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