April 3, 2025
We’re changing prior authorization requirements for members of Medicare Advantage and Healthy Montana Kids to reflect new, replaced or removed codes.
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.
Following is a summary of changes:
- July 1, 2025 – Addition of specialty drug codes to be reviewed by eviCore (Medicare)
- July 1, 2025 – Addition of lab codes to be reviewed by eviCore
More information: For a revised list of codes for Medicare Advantage plans, refer to prior authorization requirements.
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.
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.
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 Blue Cross and Blue Shield of Montana.
CPT copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSMT.
BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.