Prior Authorization Code Updates for Medicaid, Effective April 1, 2026

Jan. 30, 2026

We’re changing prior authorization requirements that may apply to Medicaid members.

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 Medicare & Medicaid Services.

Services and members, prior authorization is through Blue Cross and Blue Shield of Texas. Utilization management and related services for Medicaid members will be reviewed by BCBSTX.

These changes for Medicaid members begin April 1, 2026:

Addition of Sleep Medicine Testing codes to be reviewed by BCBSTX
Addition of DME Services and Supply codes to be reviewed by BCBSTX
Addition of Specialty Drug codes to be reviewed by BCBSTX

These changes for Medicaid members begin April 1, 2026:

Removal of multiple DME Services and Supply codes previously reviewed by BCBSTX
Removal of multiple Oral & Maxillofacial Surgery or Plastic & Reconstructive Surgery codes previously reviewed by BCBSTX
Removal of multiple orthopedic and general surgical codes previously reviewed by BCBSTX
Removal of multiple Dermatologic codes previously reviewed by BCBSTX
Removal of multiple Diagnostic Services codes previously reviewed by BCBSTX
Removal of multiple Rehab and Therapy codes previously reviewed by BCBSTX
Removal of multiple Specialty Drug codes previously reviewed by BCBSTX
Removal of multiple Orthotics/Prosthetics codes previously reviewed by BCBSTX
Removal of several Behavioral Health Services codes previously reviewed by BCBSTX

For more information, refer to prior authorization lists in utilization management.

Always check eligibility and benefits first through Availity^®Essentials or your preferred vendor 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.