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FAQ Update: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026
Act
by Dec 31, 2025
Effective date
Jan 1, 2026
Identified
Sep 29, 2026
Summary
Effective January 1, 2026, Blue Cross and Blue Shield of Texas is transferring prior authorization review for five care categories (advanced imaging, musculoskeletal, sleep, medical specialty drugs, and genetic testing) from EviCore to BCBSTX for Medicare Advantage members. Providers must submit prior authorization requests for these services directly to BCBSTX instead of EviCore for dates of service on or after January 1, 2026.
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What to do
by Dec 31, 2025 · 6 steps
01Billing team must identify all prior authorization workflows for Medicare Advantage members in the five affected care categories (advanced imaging, musculoskeletal, sleep, medical specialty drugs, genetic testing).
02Update billing system routing rules to submit these requests directly to BCBSTX instead of EviCore, effective January 1, 2026.
03Update provider education materials, encounter forms, and pre-authorization checklists to reflect the new submission pathway.
04Verify staff can access BCBSTX prior authorization submission portals (Availity Essentials or other vendor portals).
05Establish verification step to confirm eligibility and prior authorization requirements through appropriate portal before submission.
06Test updated workflows with sample requests before the effective date.
If missed: Failure to route requests to the correct entity will result in processing delays and potential claim denials.
Original notice
FAQ Update: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026
bcbstx.com · Always check the source before changing claims.
Related changes
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