See Changes to Prior Authorization for Medicare Advantage

Effective Jan. 1, 2026, we’ll review prior authorization requests for certain care categories that previously were reviewed by EviCore healthcare. Learn what’s changing.

BlueApprovR^SM To Accept Concurrent Reviews and Extensions for Behavioral Health Services

We’ll soon expand the capabilities of BlueApprovR, our utilization management tool integrated with Availity^® Essentials, to further expedite approvals for behavioral health services. Learn how to attend a training.

See Changes to Coverage for Breast Cancer Screening

We’re updating coverage for certain commercial members to align with federal guidance, effective Jan. 1, 2026.

Enhanced Diagnosis Claim Edits To Follow CMS Guidelines

Effective March 1, 2026, we’ll enhance our claims editing process for many commercial members to help ensure accurate coding and proper reimbursement of services.

Use Proper Coding for Evaluation and Management Services, Modifiers and Oncology Drugs and Services

Effective March 1, 2026, we’ll enhance our claims editing and review process for Medicare and Medicaid claims to monitor the proper use of evaluation and management coding, oncology drugs and services coding, and Modifiers 25 and 59.

Follow‑Up Care Is Recommended for Children Prescribed ADHD Medication

Attention‑deficit/hyperactivity disorder is one of the most common behavioral health disorders affecting children. To support quality care, we gather data on follow‑up visits for children using ADHD medication.

Explore Learning Opportunities

We offer free training for providers who participate in our networks. Review and sign up for sessions.

Learn About Updates to 2026 Primary Care Quality Improvement Program

The program rewards Medicaid primary care providers for exceeding benchmarks on qualifying measures. Review the measures and incentive amounts.

Providers May Use Mother’s Medicaid ID When Submitting Claims for Newborns

This provision from the Texas Health and Human Services Commission helps ensure newborns have timely access to covered services until enrollment processing is complete.

See Language Updates to Hospital Bed Policies

The Texas Health and Human Services Commission updated language in the Texas Medicaid Provider Procedures Manual.

Stay Updated on Medicaid News

You can find information for STAR, STAR Kids and CHIP in Medicaid News and Updates.

Update Your Records for New Members of Blue Cross Group Medicare Advantage Open Access (PPO)^SM

If you’re a Medicare provider, you may treat these members even if you don’t participate in our Medicare Advantage or other networks.

Provide Medical Records To Support Quality Care

You may receive requests in 2026 for our members’ medical records. We collect data for Healthcare Effectiveness Data and Information Set (HEDIS^®) measures to track quality of care. Learn how you can help by promptly providing complete records for these members:

• Federal Employee Program^®

• Medicaid

• Medicare Advantage

Learn About Updates to Clinical Payment and Coding Policies

We regularly add and modify CPCPs as part of our ongoing policy review. See which policies were updated.

Review Active and Pending Medical Policies

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.