Updated prior authorization requirements for Medicare Advantage, Experience Health, and D-SNP plans effective October 1, 2026

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will update prior authorization requirements for Medicare Advantage (MA), Experience Health, and Dual Eligible Special Needs Plan (D-SNP) products for dates of service on or after October 1, 2026.

What is changing

• Several additional procedure codes will require prior authorization

• Codes fall into two categories:

  • Molecular Genetics Testing
  • Category III (investigational, experimental, emerging technology) codes

Provider action required

• Obtain prior authorization before rendering non-emergent services for impacted codes
• Submit required clinical documentation to support medical necessity

Why this change

This update follows Centers for Medicare & Medicaid Services (CMS) regulatory guidance and provides a more streamlined experience by reducing avoidable claim delays or post-service adjustments through verification that the service is verified as medically necessary, delivered by the right provider, and performed at the right level of care.

A complete list of affected codes and submission guidance are available on the Blue Cross NC services and CPT code search page.