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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Not stated in the notice
Identified
Jun 30, 2026
Summary
Blue Cross Blue Shield of Illinois is implementing significant prior authorization requirement changes across commercial, Medicaid, and Medicare Advantage plans effective August 1 through October 1, 2026. Changes include addition of radiology advanced imaging, sleep medicine, molecular genetic testing, medical oncology, and drug codes requiring prior authorization through different utilization management vendors (Carelon, BCBSIL, EviCore), plus removal of previously reviewed codes and implementation of a new Part B Step Therapy Program for Medicare Advantage members.
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What to do
Action · 21 steps
01PHASED IMPLEMENTATION WITH MULTIPLE EFFECTIVE DATES:
By August 1, 2026:
- Medicaid: Billing team must remove prior authorization requirements for miscellaneous codes previously reviewed by BCBSIL.
02Update billing system to reflect removal.
03Verify changes in Availity Essentials before submitting claims.
04- Medicare Advantage: Billing team must implement new Part B Step Therapy Program.
05Configure billing system and eligibility verification tools to reflect new step therapy requirements.
06Providers must understand which services require step therapy review.
07- Medicare Advantage: Remove prior authorization requirements for miscellaneous codes previously reviewed by BCBSIL in billing system.
08By September 1, 2026:
- Medicaid: Billing team must update drug code prior authorization requirements.
09Replace previously reviewed drug codes with new drug codes reviewed by BCBSIL in billing system.
10Update authorization workflows.
11By October 1, 2026 (CRITICAL DATE):
- Commercial: Billing team must implement prior authorization for: (1) radiology advanced imaging codes reviewed by Carelon, (2) sleep medicine codes reviewed by Carelon, (3) molecular genetic lab testing codes reviewed by Carelon, (4) medical oncology codes reviewed by Carelon, (5) drug codes reviewed by BCBSIL.
12Remove prior authorization requirements for molecular genetic testing codes previously reviewed by other entities.
13Update all billing software authorization rules, encounter forms, and provider templates to require Availity Essentials eligibility checks before service delivery.
14- Medicare Advantage: Implement miscellaneous changes to Part B Step Therapy Program.
15Update system configurations and provider education materials.
16- Medicare Advantage: Implement prior authorization for select Proton Beam codes reviewed by BCBSIL.
17ONGOING REQUIREMENTS (All Effective Dates):
- All staff must check eligibility and benefits through Availity Essentials or preferred vendor BEFORE rendering services for all affected plans to confirm current prior authorization requirements and utilization management vendors.
18- Providers must understand: Services performed without required prior authorization or failing to meet medical necessity criteria will result in claim denials, and providers may not seek reimbursement from members.
19- Billing team should submit voluntary recommended clinical review requests when clinically indicated to avoid post-service medical necessity denials.
20- Medical billing staff must verify which vendor (Carelon, BCBSIL, or EviCore) reviews each service based on member plan type and effective date.
21- Maintain updated code lists from utilization management resources for all three vendor categories.
Original notice
Prior Authorization Changes for Some Commercial and Government Program Members
bcbsil.com · Always check the source before changing claims.
Related changes
See all BCBS Illinois changes →Prior Authorization Changes for Some Commercial and Government Program MembersHighEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial and Government Program MembersHighEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial and Government Program MembersMediumEffective Oct 1, 2026 · Prior AuthorizationUpdate: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026HighEffective Jan 1, 2026 · Prior AuthorizationBrowse every BCBS Illinois change in the policy list