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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Oct 1, 2026
Identified
Jul 28, 2026
Summary
Blue Cross Blue Shield of Illinois is changing prior authorization requirements for commercial non-HMO members and Medicare Advantage/Community Health Plan members effective October 1, 2026 (commercial) and August 1, 2026 (Medicare Advantage). Musculoskeletal and select outpatient service codes will be removed from CarelonMBM and BCBSIL review for commercial members, while miscellaneous codes are being shifted between review vendors for Medicare Advantage members. Billing teams must verify eligibility and current prior authorization requirements through Availity Essentials before service delivery.
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What to do
Action · 5 steps
01Before 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.
02Update billing software and prior authorization protocols accordingly.
03Implement 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.
04Educate providers that services rendered without required prior authorization may be denied and providers cannot balance-bill members for these denials.
05Note: 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.
Original notice
Prior Authorization Changes for Some Commercial and Government Program Members
bcbsil.com · Always check the source before changing claims.
Related changes
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