Prior Authorization Changes for Medicare Advantage and Healthy Montana Kids, Effective Oct. 1, 2025

June 30, 2025 (Updated July 9, 2025)

We’re changing prior authorization requirements for members of Medicare Advantage and Healthy Montana Kids to reflect new, replaced or removed codes due to 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. 

Utilization management and related services for government program members will be reviewed by EviCore healthcare.

Here is a summary of changes, effective Oct. 1, 2025:

  • Removal of musculoskeletal codes previously reviewed by EviCore
  • Removal of specialty drug code previously reviewed by EviCore
  • Addition of specialty drug codes to be reviewed by EviCore
  • Addition of lab codes to be reviewed by EviCore
  • Proton beam codes previously reviewed by Blue Cross and Blue Shield of Montana to be reviewed by EviCore

For a revised list of codes for Medicare Advantage plans, refer to prior authorization requirements. 

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.

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.

CPT copyright 2024 AMA. All rights reserved. CPT is a registered trademark of the AMA.

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. 

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.