Jan. 28, 2026
We’re changing prior authorization requirements that may apply to some commercial members and members with Healthy Montana Kids and Medicare Advantage plans.
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.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Montana. Utilization management and related services for members with Medicaid will be reviewed by Carelon Medical Benefits Management. Utilization management and related services for members with Medicare Advantage will be reviewed by BCBSMT and EviCore healthcare. Carelon Medical Benefits Management and Alacura Medical Transportation Management will review utilization management and related services for some commercial and HMK members.
These changes for commercial members begin April 1, 2026:
- Addition of medical transportation management codes to be reviewed by Alacura
- Addition of an advanced imaging code to be reviewed by Carelon
These changes for members of Medicare Advantage begin April 1, 2026:
- Addition of miscellaneous codes to be reviewed by BCBSMT
These changes for members of HMK began Jan. 1, 2026:
- Removal of lab codes previously reviewed by EviCore
- Removal of radiation therapy codes reviewed by EviCore
- Addition of lab codes reviewed by Carelon
- Addition of medical oncology codes reviewed by Carelon
- Addition of musculoskeletal spine codes reviewed by Carelon
For a revised list of codes, refer to prior authorization and recommended clinical review.
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.
CPT copyright 2025 AMA. All rights reserved. CPT is a registered trademark of the AMA.
Alacura Medical Transportation Management, LLC. is an independent company that has contracted with BCBSMT to provide utilization management services for participants 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. Carelon Medical Benefits Management is an independent company that has contracted with BCBSMT to provide utilization management services for members with coverage through 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.