Sept. 2, 2025
We’re changing prior authorization requirements that may apply to some commercial non-HMO members and members with Blue Cross Medicare Advantage (PPO)SM, Blue Cross Community Health PlansSM or Blue Cross Community MMAI (Medicare-Medicaid Plan)SM.
Changes are based on 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 Medicaid & Medicare Services.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Illinois. Utilization management and related services for MMAI and Medicare Advantage members will be reviewed by Evicore healthcare. Carelon Medical Benefits Management will review utilization management and related services for some commercial members and those with BCCHPSM.
These changes for commercial members begin Oct. 1, 2025:
- Removal of deactivation of headache trigger codes previously reviewed by BCBSIL
These changes for members of BCCHP begin Oct. 1, 2025:
- Removal of lab/genetic testing codes previously reviewed by Carelon or BCBSIL
- Removal of rehabilitation (PT/OT/ST) codes previously reviewed by Carelon or BCBSIL
- Removal of outpatient medical and surgical services previously reviewed by BCBSI
- Removal of radiology codes previously reviewed by Carelon
- Removal of musculoskeletal codes previously reviewed by Carelon
These changes for members of BCCHP begin Nov. 1, 2025:
- Addition of lab, radiation therapy and rehabilitation (PT/OT/ST) codes to be reviewed by Carelon
- Medical drugs previously reviewed by Prime Therapeutics will now be reviewed by BCBSIL
- Rehabilitation (PT/OT/ST) codes previously reviewed by BCBSIL will now be reviewed by Carelon
Prior authorization reminders for members of BCCHP
- Carelon will only review medical oncology drugs with a corresponding oncology diagnosis. If a medical oncology drug is being used for a non-oncology diagnosis, the prior authorization request should be submitted to BCBSIL.
For more information and code lists, refer to utilization management.
There will be more information included in the prior authorization list for members of BCCHP. The list has recently been updated to align with State of Illinois regulation: Section 140.76, Managed Care Utilization Review Standardization and Transparency Practices. It now includes:
- Access and instructions to specific payment and clinical review criteria, guidelines and policies
- A date column to indicate when the prior authorization requirement was posted to the website
In addition, there will be a new Procedure Code List Change Summary document. The "Procedure Code List Change Summary will include:
- CPT and HCPCS codes impacted
- Who the prior authorization reviewer was at the time of the change
- What the change entails: code removed, added or changed, or reviewer change
- Effective date of change
- Rationale for change
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.
Even if prior authorization isn’t required, you still may want to submit a voluntary recommended clinical review request. This step can help avoid postservice medical necessity review. Checking eligibility and benefits can’t tell you when to request recommended clinical review, since it’s optional. But there’s a medical policy reference list on our recommended clinical review page to help you decide.
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 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
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 certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
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 BCBSIL. EviCore Healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.