Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026
AI Summary
Effective January 1, 2026, Blue Cross Blue Shield of Texas is taking over prior authorization review for Medicare Advantage members in five care categories that were previously handled by EviCore healthcare. Billing teams must now submit prior authorization requests for advanced imaging, musculoskeletal services, sleep studies, medical specialty drugs, and genetic testing directly to BCBSTX instead of EviCore.
Action Required
Immediately: Update prior authorization submission workflows to send requests for Medicare Advantage members to BCBSTX instead of EviCore for these five categories: advanced imaging, musculoskeletal services, sleep studies, medical specialty drugs, and genetic testing. Train billing staff on the new submission process and update internal procedures. Continue checking eligibility and benefits through Availity Essentials to confirm prior auth requirements and proper submission vendor for each request.
Plan Types
Medicare Advantage
States
TX
Specialties
radiology, ortho, sleep-medicine, oncology, hematology, endocrinology, rheumatology, neurology, pain-management, pm-r, diagnostic-imaging, laboratory