BCBS MontanaMedicare Advantage · Prior Auth · Prior Authorization · MT · General Surgery, Orthopedics, Plastic Surgery +7 moreHigh impact
Prior Authorization Changes for Some Government Program Members
Act
by Dec 21, 2026
Effective date
Dec 21, 2026
Identified
Oct 31, 2026
Summary
Blue Cross and Blue Shield of Montana is removing prior authorization requirements for specific procedure categories (proprietary laboratory analyses, drugs and biologics, molecular pathology/genetics, infectious disease molecular testing, radiology and advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, ophthalmology, and miscellaneous specialty procedures) for Medicare Advantage members effective December 21, 2026. Additionally, the organization will begin phasing out Recommended Clinical Review options starting January 1, 2027, with complete removal expected by end of 2027 for most commercial members.
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01Billing team must update prior authorization workflows in billing software and claims submission processes to remove prior authorization requirements for Medicare Advantage members seeking the listed procedure categories (laboratory analyses, drugs/biologics, molecular pathology/genetics, infectious disease molecular testing, radiology, advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, and ophthalmology procedures).
02Verify updated code lists on BCBSMT's website.
03Effective January 1, 2027: Commercial billing staff should begin transitioning workflows to discontinue submitting Recommended Clinical Review requests, as this option will be phased out entirely by end of 2027 for most commercial members.
04Staff should check Availity® Essentials or preferred vendor before rendering services to confirm current prior authorization requirements and applicable utilization management vendors.
05Note: Services rendered without required prior authorization may result in claim denial and providers cannot seek reimbursement from members.
Original notice
Prior Authorization Changes for Some Government Program Members
bcbsmt.com · Always check the source before changing claims.
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