Important Prior Authorization Changes to Care Categories for Medicaid Members, Effective May 1, 2024


What’s Changing: Blue Cross and Blue Shield of Texas is changing prior authorization requirements for Medicaid members due to updates from Utilization Management prior authorization assessment.

Changes effective May 1, 2024 include:

  • Transfer of all prior authorization requirements for Specialty Pharmacy and Musculoskeletal care categories from eviCore Healthcare (eviCore) to BCBSTX
  • Removal of prior authorization requirements for Sleep, Radiology, Medical Oncology and Lab care categories previously reviewed by eviCore

Refer to Prior Authorization Lists and Reports on the Utilization Management section of our Medicaid provider website.

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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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 (eviCore) 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.