Prior Authorization Changes for Some Commercial and Government Program Members

By October 1, 2026: Billing team must update prior authorization workflows for all affected member types. (1) For Commercial members: Remove behavioral health codes from BCBSIL prior auth requirements and transition to new vendor processes. (2) For Medicaid members: Remove miscellaneous codes from BCBSIL review and implement replacement codes through the new process. (3) For Medicare Advantage members: Remove oncology, immunology/specialty infusion, and laboratory/molecular diagnostic codes from BCBSIL; add replacement oncology codes back to BCBSIL. By January 1, 2027: (1) For Commercial members: Remove remaining miscellaneous codes from Carelon review and add radiation oncology codes to Carelon review. (2) For Medicare Advantage members: Add miscellaneous codes and Emerging Technology/Services/Procedures codes to BCBSIL review. In all cases, verify member eligibility and benefits through Availity Essentials or preferred vendor BEFORE rendering services to confirm current prior authorization requirements and applicable vendors. Failure to obtain required prior authorization will result in claim denials and providers cannot seek reimbursement from members. Update all billing system rules, encounter forms, and staff training to reflect the applicable vendor assignments for each member plan type.