BCBS TexasMedicare Advantage · Prior Auth · Prior Authorization · TX · Orthopedics, General Surgery, Vascular 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 Texas is removing prior authorization requirements for specific service categories (laboratory analyses, drugs/biologics, molecular pathology, infectious disease testing, radiology, 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 plan will begin reducing and eventually eliminating the 'Recommended Clinical Review' option from utilization management processes for most commercial members by end of 2027, with ERS and TRS excluded from this change.
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01Billing team must update prior authorization workflows to remove requirements for the listed service 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, ophthalmology, and miscellaneous specialty procedures) for Medicare Advantage members.
02Verify current prior authorization requirements through Availity® Essentials or preferred vendor before rendering services.
03By end of 2027: Review and update workflows to eliminate the 'Recommended Clinical Review' option for commercial members in internal utilization management processes (ERS and TRS plans are excluded).
If missed: Failure to follow updated prior authorization requirements may result in claim denials, and services performed without required prior authorization may be denied for payment with no member balance billing.
Original notice
Prior Authorization Changes for Some Government Program Members
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