Changes to Our Prior Authorization Programs for Medicare Advantage
AI Summary
Effective January 1, 2026, prior authorization requests for Medicare Advantage members in several care categories (Advanced Imaging, Musculoskeletal, Sleep, Medical Specialty Drugs, Genetic Testing) must now be submitted to BCBSTX instead of EviCore. The change reduces prior authorization requirements to fewer than 20% of codes and aims to streamline the process.
Action Required
Immediately: Billing team must redirect all prior authorization requests for Medicare Advantage members in Advanced Imaging, Musculoskeletal, Sleep, Medical Specialty Drugs, and Genetic Testing categories from EviCore to BCBSTX. Update workflow procedures to call the number on member ID cards or check Availity Essentials to verify authorization requirements. Review updated prior authorization code lists on BCBSTX website. Note: Continue submitting Proton Beam Therapy requests to EviCore.
Plan Types
Medicare Advantage
States
TX
Specialties
radiology, ortho, sleep-medicine, oncology, all-specialties