Prior Authorization Changes for Some Commercial and Government Program Members
AI Summary
Blue Cross Blue Shield of Texas is implementing staged prior authorization changes affecting multiple member types. Medicare Advantage members will have new miscellaneous codes requiring prior auth starting April 1, 2026, while Medicaid members will see code removals in April and additions in July. Commercial members will have new advanced imaging prior auth requirements starting July 1, 2026.
Action Required
By March 31, 2026: Billing team must verify updated prior authorization lists in BCBSTX utilization management section for specific affected codes. Update billing system workflows to check eligibility through Availity Essentials before rendering services for all BCBSTX members. Train staff on new review entities: BCBSTX/EviCore for Medicare Advantage, Carelon/Alacura for commercial members. Failure to obtain required prior authorization may result in claim denials with no patient billing allowed.
Plan Types
Medicare Advantage, Medicaid, Commercial
States
TX
Specialties
all-specialties