Prior Authorization Changes for Some Commercial and Government Program Members
AI 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).
Action Required
By December 31, 2025: Billing team must update prior authorization workflows for two implementation phases. Phase 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. Phase 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. Always verify current prior auth requirements through Availity Essentials before service delivery. Failure to obtain required prior authorization may result in claim denials with no patient billing allowed.
Plan Types
Commercial, Medicare Advantage
States
TX
Specialties
radiology, oncology, ortho, laboratory, diagnostic-imaging, sleep-medicine, all-specialties