Prior Authorization Changes for Some Commercial and Government Program Members

REQUIREMENTS: 1. BY OCTOBER 1, 2026: - Billing team must remove behavioral health codes from BCBSMT prior authorization requirements for commercial members - Update billing software to reflect this removal in the prior auth submission rules - Notify providers that behavioral health codes will no longer require BCBSMT prior authorization - Consequence: Submitting unnecessary prior auth requests may delay claims processing 2. BY JANUARY 1, 2027: - Billing team must remove miscellaneous codes from Carelon prior authorization requirements for commercial members - Billing team must add radiation oncology codes to Carelon prior authorization requirements for commercial members - Billing team must add miscellaneous codes to BCBSMT prior authorization requirements for Medicare Advantage members - Billing team must add Emerging Technology, Services & Procedures codes to BCBSMT prior authorization requirements for Medicare Advantage members - Update billing software routing logic to direct claims to correct utilization management vendor based on plan type and code category - Review the revised code list provided by BCBSMT and verify all affected codes are correctly mapped in the system - Train billing staff on new submission requirements for each plan type - Consequence: Routing claims to incorrect reviewers will result in claim delays, denials, or rework 3. IMMEDIATELY: - Billing team must obtain and review the complete revised prior authorization code list from BCBSMT website - Identify which codes your practice bills fall under the affected categories (behavioral health, miscellaneous, oncology, immunology/specialty infusion, laboratory/molecular diagnostic, radiation oncology, emerging technology) - Document current prior authorization workflows for each affected code category - Plan system updates with IT/billing software vendor to ensure changes are deployed before each effective date