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Prior Authorization Changes for Some Commercial and Government Program Members
Act
by Oct 1, 2026
Effective date
Oct 1, 2026
Identified
Sep 1, 2026
Summary
Blue Cross and Blue Shield of Illinois is restructuring prior authorization requirements for commercial non-HMO, Medicare Advantage, and Medicaid members by removing certain procedure code categories from review and shifting others to different utilization management vendors (Carelon, EviCore, or BCBSIL). Changes occur in three phases: October 1, 2026 (behavioral health and oncology removals/replacements), January 1, 2027 (miscellaneous and radiation oncology additions), and an August 1, 2026 change already in effect for Medicare Advantage miscellaneous codes.
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What to do
by Oct 1, 2026 · 10 steps
01Billing team must update prior authorization workflows for all affected member types.
02For Commercial members: Remove behavioral health codes from BCBSIL prior auth requirements and transition to new vendor processes.
03For Medicaid members: Remove miscellaneous codes from BCBSIL review and implement replacement codes through the new process.
04For Medicare Advantage members: Remove oncology, immunology/specialty infusion, and laboratory/molecular diagnostic codes from BCBSIL; add replacement oncology codes back to BCBSIL.
05By January 1, 2027.
06For Commercial members: Remove remaining miscellaneous codes from Carelon review and add radiation oncology codes to Carelon review.
07For Medicare Advantage members: Add miscellaneous codes and Emerging Technology/Services/Procedures codes to BCBSIL review.
08In 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.
09Failure to obtain required prior authorization will result in claim denials and providers cannot seek reimbursement from members.
10Update all billing system rules, encounter forms, and staff training to reflect the applicable vendor assignments for each member plan type.
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 MembersMediumEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial and Government Program MembersHighNo effective date · 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