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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Not stated in the notice
Identified
Sep 1, 2026
Summary
Blue Cross Blue Shield of Texas is updating prior authorization (PA) requirements for Commercial, Medicare Advantage, and Medicaid members effective on three different dates between October 2026 and January 2027. Changes include removal of behavioral health and miscellaneous codes from PA requirements for Commercial members, addition of radiation oncology codes, replacement of oncology codes for Medicare, and addition of specific drug codes for Medicaid. Billing teams must verify eligibility and PA requirements through Availity before service delivery, as claims without required PA will be denied and providers cannot bill members.
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What to do
Action · 8 steps
01REQUIREMENTS:
By October 1, 2026: Billing team must update prior authorization workflows to REMOVE behavioral health codes from PA requirements for Commercial members.
02Verify current PA lists in utilization management portal and update billing software accordingly.
03By November 1, 2026: Billing team must update system to ADD Itvisma drug code to PA requirements for Medicaid members reviewed by BCBSTX.
04Ensure pharmacy and clinical staff are notified.
05By January 1, 2027: Billing team must:
- REMOVE miscellaneous codes from PA requirements for Commercial members (Carelon)
- ADD radiation oncology codes to PA requirements for Commercial members (Carelon)
- ADD miscellaneous codes to PA requirements for Medicare Advantage members (BCBSTX)
- ADD Emerging Technology, Services & Procedures codes to PA requirements for Medicare Advantage members (BCBSTX)
Immediate and ongoing: Before every service delivery, front desk and clinical staff MUST check eligibility and benefits through Availity Essentials or preferred vendor to confirm current PA requirements and applicable utilization management vendors.
06Update encounter forms and pre-visit processes to include this verification step.
07CONSEQUENCES: Claims submitted without required prior authorization will be DENIED for payment.
08Providers may NOT bill members for denied claims.
If missed: Failure to verify PA requirements before service delivery creates financial risk.
Original notice
Prior Authorization Changes for Some Commercial and Government Program Members
bcbstx.com · Always check the source before changing claims.
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