Prior Authorization Changes for Some Commercial and Government Program Members

Before October 1, 2026 (and August 1, 2026 for Medicare Advantage members): Billing team must obtain the specific code lists from BCBSIL's utilization management webpage to identify which musculoskeletal codes and outpatient service codes are being removed from prior authorization requirements for commercial members, and which miscellaneous codes are being added/removed for Medicare Advantage members. Update billing software and prior authorization protocols accordingly. Implement workflow to consistently check eligibility and benefits through Availity Essentials or preferred vendor for all BCBSIL commercial and Medicare Advantage members BEFORE rendering services to confirm current prior authorization requirements and applicable utilization management vendors. Educate providers that services rendered without required prior authorization may be denied and providers cannot balance-bill members for these denials. Note: The policy references specific code lists but does not include them in the document—contact BCBSIL or check their utilization management portal for the complete lists before the effective dates.