Prior Authorization Changes for Medicare Advantage Members Effective Jan. 1, 2025

Nov. 1, 2024

We’re changing prior authorization requirements for Medicare Advantage members 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 changes from the Centers for Medicaid & Medicare Services. Changes include:

  • Jan. 1, 2025 – Removal of medical oncology and supportive care codes previously reviewed by eviCore healthcare
  • Jan. 1, 2025 – Medical oncology drug codes previously reviewed by eviCore to be reviewed by Blue Cross and Blue Shield of New Mexico

For the revised list of codes, refer to prior authorization CPT code links under preservice reviews. The code changes are designated with dates of removal or addition.

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.

Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. 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 2023 American Medical Association. 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 BCBSNM. eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.