Traditional MedicarePrior AuthHigh impact
Prior authorization changes for February 1, 2026 – Medicare and Medicaid
PacificSource Health Plans·Orthopedics, General Surgery, ENT (Ear, Nose & Throat) +10 more·Prior Authorization
Effective date
Feb 1, 2026
We identified it
Dec 8, 2025
Summary
Effective February 1, 2026, PacificSource is implementing new prior authorization requirements for Medicare and Medicaid. Medicare adds 20 procedure codes requiring prior auth (including arthroscopy, unlisted procedures, and specialized diagnostics) plus 3 codes requiring prior auth only when claims exceed $500. Medicaid adds 2 codes requiring prior auth. Billing teams must update systems and verify all affected codes before service delivery to avoid claim denials.
Action Required
By January 31, 2026: Billing team must update system configuration to require prior authorization for all 23 affected codes. For Medicare: codes C9781, E0486, 29999, 31299, 31599, 31899, 39599, 43659, 47379, 49329, 50949, 51999, 60699, 64912, 64999, 78499, 93702, 95965, 95966, and 97799 require prior auth for all amounts; codes L2999, L8699, and 37243 require prior auth only when claim amount exceeds $500. For Medicaid: codes 64912 and 93702 require prior auth for all amounts. Providers must verify prior authorization status using PacificSource's Provider Authorization Grid tool BEFORE rendering services. Update encounter forms and clinical workflows to include prior auth verification checkpoints. Communicate changes to all clinical staff. Failure to obtain required prior authorization will result in claim denials.