Nov. 21, 2025
We’re changing prior authorization requirements that may apply to some Medicaid members plan.
Changes are based on updates from utilization management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System code changes from the Centers for Medicaid & Medicare Services.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Texas. Utilization management and related services for Medicaid members will be reviewed by Blue Cross and Blue Shield of Texas.
These changes for members of government program Medicaid began Oct. 1, 2025, and reviewed by Blue Cross and Blue Shield of Texas:
- Addition of DME and supply codes
- Addition of Orthotics codes
- Addition of Genetic Testing codes
- Addition of Specialty Drug codes
These changes for members of government program Medicaid begin Jan. 1, 2026, and reviewed by Blue Cross and Blue Shield of Texas:
- Addition and removal of DME codes
- Addition of Gene Therapy codes
Note: after annual review there are additional changes coming Jan. 1, 2026, across many categories for Medicaid. See the prior authorization code list for specific changes.
More Information: Refer to Prior Authorization Lists in Utilization Management.
Important Reminder: Always check eligibility and benefits first through the Availity® Essentials provider portal or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s coverage contract or guide. If you have any questions, call the number on the member's ID card.
Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
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Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.