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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Oct 1, 2026
Identified
Sep 1, 2026
Summary
Blue Cross Blue Shield of Oklahoma is restructuring prior authorization requirements for commercial and Medicare Advantage members effective October 1, 2026, and January 1, 2027. Behavioral health codes are being removed from BCBSOK review for commercial members, while new code categories (radiation oncology, miscellaneous codes, and emerging technology procedures) are being added to different utilization management vendors. Billing teams must verify eligibility and confirm which vendor handles prior authorization for each service, as requirements vary by plan type and effective date.
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What to do
Action · 9 steps
01REQUIREMENTS:
By September 15, 2026: Billing team and providers must update internal prior authorization tracking systems and workflows to reflect the October 1, 2026 changes:
- For COMMERCIAL PLANS: Remove behavioral health codes from BCBSOK prior authorization requirements (they will no longer require pre-approval through BCBSOK).
02- For MEDICARE ADVANTAGE PLANS: Remove oncology, immunology/specialty infusion, and laboratory/molecular diagnostic codes from BCBSOK prior authorization requirements; these will now be reviewed by EviCore Healthcare instead.
03- Update encounter forms, billing templates, and staff training materials to reflect new vendor assignments.
04By December 15, 2026: Billing team must prepare for January 1, 2027 changes:
- For COMMERCIAL PLANS: Remove miscellaneous codes from Carelon review and add radiation oncology codes to Carelon's review scope in billing system rules.
05- For MEDICARE ADVANTAGE PLANS: Add miscellaneous codes and Emerging Technology, Services & Procedures codes to BCBSOK's prior authorization requirements.
06- Update all staff on new code categories requiring prior authorization.
07ONGOING: Before rendering ANY service, staff must use Availity Essentials or preferred vendor to verify current eligibility, benefits, and which vendor (BCBSOK, EviCore Healthcare, Carelon Medical Benefits Management, or Alacura Medical Transportation Management) handles prior authorization for that specific code and plan type.
08CONSEQUENCES: Services performed without required prior authorization or that do not meet medical necessity criteria will be denied for payment.
09Rendering providers may not seek reimbursement from members for denied claims due to missing prior authorization.
Original notice
Prior Authorization Changes for Some Commercial and Government Program Members
bcbsok.com · Always check the source before changing claims.
Related changes
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