Upcoming Authorization Changes for Blue Cross Members in 2026 What You Need to Know

Starting January 1, 2026, Blue Cross will implement authorization changes for some commercial and government program members. These changes will affect how healthcare providers request and receive approvals for certain services. Understanding these updates is essential for providers to ensure smooth patient care and avoid delays in treatment.

What Are the Authorization Changes Coming to Blue Cross?

The authorization changes coming to Blue Cross for some commercial and government program members effective 01/01/2026 will introduce new requirements for prior authorizations. These changes aim to improve the review process but will require providers to adjust their workflows.

Key points include:

• Expanded list of services requiring prior authorization

• Updated submission procedures for authorization requests

• New timelines for response from Blue Cross

• Enhanced documentation requirements

  
  

Providers should expect more detailed information requests to support medical necessity and eligibility. This means preparing thorough clinical documentation will become even more important.

Which Members Will Be Affected?

Not all Blue Cross members will experience these changes. The updates specifically target:

• Certain commercial insurance plans

• Select government programs, including Medicaid and Medicare Advantage plans

  
  

Providers should verify patient coverage details before submitting authorization requests to confirm if the new rules apply. Blue Cross will provide member-specific communications to clarify eligibility.

How Will These Changes Impact Healthcare Providers?

The authorization changes coming to Blue Cross for some commercial and government program members effective 01/01/2026 will affect providers in several ways:

• Increased administrative tasks: More detailed forms and documentation will require additional time to complete.

• Longer processing times: Although Blue Cross aims to improve efficiency, initial adjustments may cause delays.

• Potential for more denials: Incomplete or insufficient documentation could lead to higher denial rates.

• Need for staff training: Teams must stay informed about new procedures to avoid errors.

  
  

Providers should review their current authorization processes and identify areas for improvement. Investing in staff education and electronic submission tools can help manage the increased workload.

These changes for commercial members begin Jan. 1, 2026:

• Addition of Advanced Imaging codes to be reviewed by Carelon

• Addition of Sleep codes to be reviewed by Carelon

• Addition of Genetic Testing codes to be reviewed by Carelon

These changes for members of government programs begin Jan. 1, 2026:

• Addition of Specialty Drug codes to be reviewed by EviCore

• Addition of Molecular Genetic Lab Testing codes to be reviewed by EviCore

Note: after annual review there are additional changes coming Jan. 1, 2026, across many categories for Medicare Advantage. See the prior authorization code list for specific changes.

Additional Details: See the Prior Authorization Lists under Utilization Management.  

Important Reminder: Before providing services, always verify eligibility and benefits using the Availity^® Essentials provider portal or your chosen vendor portal. This will confirm any prior authorization requirements and utilization management vendors, if necessary.

Verifying eligibility and benefits or obtaining prior authorization does not guarantee payment. Benefits will be assessed upon receipt of a claim and will depend on factors such as the member’s eligibility and the terms of their coverage contract or guide. If you have questions, please call the number on the member's ID card.

Services provided without the necessary prior authorization or that do not meet medical necessity criteria may be denied payment, and the provider cannot seek reimbursement from the member.

Common Questions Providers May Have

Will all services require prior authorization?

No, only specific services and procedures listed in the updated guidelines will require authorization.

How long will Blue Cross take to respond?

Response times may vary but Blue Cross aims to provide decisions within established timeframes, typically 3 to 7 business days.

What happens if an authorization is denied?

Providers can appeal denials by submitting additional documentation or requesting a peer-to-peer review.

Will these changes affect patient out-of-pocket costs?

Authorization changes primarily affect provider processes. However, delays in approval could impact treatment timing, which may indirectly affect patients.

Final Thoughts on the Authorization Changes

The authorization changes coming to Blue Cross for some commercial and government program members effective 01/01/2026 will require healthcare providers to adapt their workflows and documentation practices. Providers who prepare early by understanding the new requirements, enhancing their submission processes, and using available resources will reduce administrative burdens and maintain timely patient care.

Staying informed and proactive is key. Providers should watch for updates from Blue Cross and participate in training opportunities. Taking these steps will help ensure a smooth transition and continued quality care for patients.