Prior Authorization Changes for Some Commercial and Government Program Members
AI Summary
Blue Cross Blue Shield of Texas is implementing multiple prior authorization changes affecting commercial, Medicaid, and Medicare Advantage members starting April 1, 2026. New prior authorization requirements will be added for various services including oncology, advanced imaging, sleep studies, and genetic testing, with different review organizations handling different service types.
Action Required
By April 1, 2026: Billing team must update prior authorization workflows for commercial members to include new requirements for radiation oncology, advanced imaging, sleep studies, molecular genetic lab tests, medical oncology, and drug codes. Update staff training on which services require Carelon vs BCBSTX review. By July 1, 2026: Implement Part B Step Therapy requirements and new prior auth processes for orthotic, pharmacy, and miscellaneous codes for Medicare Advantage members. By June 1, 2026: Update Medicaid prior auth requirements for drug and DME codes. Always verify eligibility and prior auth requirements through Availity before rendering services - failure to obtain required prior authorization may result in claim denials and providers cannot bill members directly.
Plan Types
Commercial, Medicaid, Medicare Advantage
States
TX
Specialties
oncology, radiology, sleep-medicine, laboratory, ortho, all-specialties