Prior Authorization Changes for Some Commercial and Government Program Members, Effective Jan. 1, 2026
AI Summary
Blue Cross Blue Shield of Texas is adding new prior authorization requirements effective January 1, 2026. Commercial members will need prior auth for Advanced Imaging, Sleep studies, and Genetic Testing (reviewed by Carelon). Government program members (Medicare Advantage) will need prior auth for Specialty Drugs and Molecular Genetic Lab Testing (reviewed by EviCore).
Action Required
By January 1, 2026: Billing team must update prior authorization workflows for BCBSTX members. For commercial members: require prior auth through Carelon for Advanced Imaging, Sleep studies, and Genetic Testing codes. For Medicare Advantage members: require prior auth through EviCore for Specialty Drug and Molecular Genetic Lab Testing codes. Always verify eligibility and benefits through Availity portal before rendering services. Update staff training on new prior auth requirements. Claims without required prior authorization may be denied and providers cannot bill patients.
Plan Types
Commercial, Medicare Advantage
States
TX
Specialties
diagnostic-imaging, sleep-medicine, laboratory, all-specialties