Jan. 5, 2026
Previously, we contracted with EviCore healthcare for utilization management of several care categories for our Medicare Advantage members. Effective Jan. 1, 2026, utilization management for various care categories previously supported by EviCore will be supported by Blue Cross and Blue Shield of Texas.
Effective for dates of service on or after Jan. 1, 2026, prior authorization requests for our Medicare Advantage members should be submitted to BCBSTX for the following care categories:
- Advanced Imaging
- Musculoskeletal
- Sleep
- Medical Specialty Drugs
- Genetic Testing
Note: This change does not include Proton Beam Therapy Services, which will continue with EviCore.
This change is limited to prior authorization reviews supported by EviCore for Medicare Advantage.
Frequently Asked Questions
Q: Will there be code changes?
A: We are updating our prior authorization code requirements. Going forward, fewer than 20 percent of our codes will require prior authorization for our Medicare Advantage members. Review lists of codes requiring authorization on our website.
Q: Why is this happening?
A: The move will increase efficiency, streamline the prior authorization process, improve turnaround times and increase transparency and accountability.
Q: How can I verify if a member and service needs prior authorization?
A: Call the number on the member’s ID card or check eligibility and benefits through Availity® Essentials or your preferred vendor. This step helps confirm if prior authorization is required for a specific service and member. You’ll also be directed to the appropriate utilization management vendor, if applicable, to submit your request for review.
Q: Is there a change to how I submit claims?
A: No. There is no change to the claims submission process. Refer to the member ID card for claim information.
Q: Whom do I contact if I have questions?
A: We value your feedback and welcome inquiries. Contact your provider relations representative for more information.
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.
EviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.