June 27, 2025
We’re changing prior authorization requirements that may apply to some commercial members to reflect new, replaced or removed codes. These changes are based on updates from utilization management prior authorization assessment, including Current Procedural Terminology (CPT®) code changes or Healthcare Common Procedure Coding System code changes from the Centers for Medicaid & Medicare Services.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Montana. Utilization management and related services for some commercial members will be reviewed by Carelon Medical Benefits Management.
Here is a summary of changes, effective Oct. 1, 2025:
- Addition of genetic testing codes to be reviewed by Carelon
- Addition of a musculoskeletal code to be reviewed by Carelon
- Replacement of medical oncology drug codes to be reviewed by Carelon
- Addition of medical oncology codes to be reviewed by Carelon
- Removal of a drug therapy code previously reviewed by BCBSMT
- Addition of various drug codes to be reviewed by BCBSMT
For a revised list of codes, refer to prior authorization and recommended clinical review.
Always check eligibility and benefits first through the Availity® Essentials provider portal or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
CPT copyright 2024 AMA. All rights reserved. CPT is a registered trademark of the AMA.
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 certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSMT to provide utilization management services for members with coverage through BCBSMT.
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 BCBSMT.
BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.