Prior Authorization Changes for Some Commercial and Government Program Members

PHASED IMPLEMENTATION WITH MULTIPLE EFFECTIVE DATES: By August 1, 2026: - Medicaid: Billing team must remove prior authorization requirements for miscellaneous codes previously reviewed by BCBSIL. Update billing system to reflect removal. Verify changes in Availity Essentials before submitting claims. - Medicare Advantage: Billing team must implement new Part B Step Therapy Program. Configure billing system and eligibility verification tools to reflect new step therapy requirements. Providers must understand which services require step therapy review. - Medicare Advantage: Remove prior authorization requirements for miscellaneous codes previously reviewed by BCBSIL in billing system. By September 1, 2026: - Medicaid: Billing team must update drug code prior authorization requirements. Replace previously reviewed drug codes with new drug codes reviewed by BCBSIL in billing system. Update authorization workflows. By 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. Remove prior authorization requirements for molecular genetic testing codes previously reviewed by other entities. Update all billing software authorization rules, encounter forms, and provider templates to require Availity Essentials eligibility checks before service delivery. - Medicare Advantage: Implement miscellaneous changes to Part B Step Therapy Program. Update system configurations and provider education materials. - Medicare Advantage: Implement prior authorization for select Proton Beam codes reviewed by BCBSIL. ONGOING 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. - 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. - Billing team should submit voluntary recommended clinical review requests when clinically indicated to avoid post-service medical necessity denials. - Medical billing staff must verify which vendor (Carelon, BCBSIL, or EviCore) reviews each service based on member plan type and effective date. - Maintain updated code lists from utilization management resources for all three vendor categories.