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CommercialPrior AuthHigh impact

Medicaid and Commercial Prior Authorization Changes

PacificSource Health Plans·Cardiology, Cardiothoracic Surgery, Pulmonology +3 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Nov 10, 2025
Days to comply

Summary

Effective January 1, 2026, both Commercial and Medicaid plans are implementing new prior authorization requirements for specific CPT/HCPCS codes. Additionally, certain HCPCS codes for Medicaid require prior authorization only when item costs exceed $500. The billing team must identify affected codes and implement authorization workflows before services are rendered.

Action Required

Action needed
By December 15, 2025: Billing team must complete the following: (1) Access PacificSource's Provider Authorization Grid tool and LineFinder tool to verify all affected codes listed in this policy; (2) Update billing software to flag and require prior authorization for all Commercial and Medicaid claims using the specified CPT codes (33249, 33285, 78499, 93454, 93456, 93489, 93460, 21120, 21121, 21122, 21123, 21199, 92999, 99999, 30520, 31593, 31899, 39599, 94365, 94737, 94932, 94950, 94951, 99960, 99964, 99978, 99E08, 49); (3) Configure Medicaid-specific authorization rules for HCPCS codes (L8699, L1499, E1399, L7499, L2999, K0108) to trigger prior authorization only when item cost exceeds $500; (4) Update pre-service workflows so front desk and clinical staff initiate prior authorization requests before scheduling or rendering services; (5) Train all relevant staff on new authorization requirements. Starting January 1, 2026, claims submitted without required prior authorization will be denied, resulting in lost revenue and patient collection issues.

Affected Billing Codes

33249
33285
78499
93454
93456
93489
93460
21120
21121
21122
21123
21199
92999
99999
30520
31593
31899
39599
94365
94737
94932
94950
94951
99960
99964
99978
49
L8699
L1499
E1399
L7499
L2999
K0108