June 30, 2025 (Updated July 9, 2025)
We’re changing prior authorization requirements for Medicare Advantage members to reflect new, replaced or removed codes due to updates from utilization management or the American Medical Association.
Utilization management and related services for Medicare Advantage members will be reviewed by EviCore healthcare.
Here is a summary of changes, effective Oct. 1, 2025:
- Removal of musculoskeletal codes previously reviewed by EviCore
- Removal of specialty drug code previously reviewed by EviCore
- Addition of specialty drug codes to be reviewed by EviCore
- Addition of lab codes to be reviewed by EviCore
- Proton beam codes previously reviewed by Blue Cross and Blue Shield of Texas to be reviewed by EviCore
For more information, refer to the prior authorization lists and to utilization management.
Check eligibility and benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity® Essentials or your preferred vendor.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without 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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EviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSTX. Availity provides administrative services to BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.