Prior Authorization Code Updates for Medicare Advantage, Effective Oct. 1, 2025
AI Summary
Blue Cross Blue Shield of Texas is updating prior authorization requirements for Medicare Advantage members effective October 1, 2025. Key changes include removing musculoskeletal codes from EviCore review, adding new specialty drug and lab codes to EviCore review, and transferring proton beam codes from BCBSTX to EviCore review.
Action Required
By October 1, 2025: Billing team must review and update prior authorization workflows for BCBSTX Medicare Advantage members. Check the updated prior authorization lists on the BCBSTX website to identify specific codes affected. Update billing system rules to reflect removed musculoskeletal codes (no longer requiring prior auth), new specialty drug and lab codes requiring EviCore review, and proton beam codes now reviewed by EviCore instead of BCBSTX. Verify prior authorization requirements through Availity Essentials before rendering services to avoid claim denials.
Plan Types
Medicare Advantage
States
TX
Specialties
ortho, oncology, diagnostic-imaging, laboratory