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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Oct 1, 2026
Identified
Oct 1, 2026
Summary
Blue Cross Blue Shield of Illinois is restructuring prior authorization requirements effective Oct 1, 2026 and Jan 1, 2027, moving genetic testing, oncology, orthotics, wound care, DME, and neurostimulator sleep codes between review vendors (Carelon and BCBSIL) and transitioning from optional Recommended Clinical Review to mandatory prior authorization for certain services. Billing teams must update systems to route these codes to the correct utilization management vendor and verify eligibility requirements before service delivery.
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What to do
Action · 10 steps
01REQUIREMENTS:
By September 15, 2026: Billing team must immediately identify all claims currently submitted for genetic testing, medical oncology therapy, provider-administered drugs, oncology drugs, orthotics, wound care, and durable medical equipment (DME) services.
02Update billing system routing rules to direct these codes to Carelon Medical Benefits Management (commercial and BCCHP members) or BCBSIL (Medicare Advantage members) based on member plan type.
03Before October 1, 2026: Verify which utilization management vendor (Carelon or BCBSIL or EviCore) will review each code category per member plan type.
04Update prior authorization submission workflows in billing system.
05Train front-desk and billing staff to:
- Always verify eligibility and benefits through Availity Essentials BEFORE rendering services
- Confirm which vendor reviews each service for the specific member's plan
- Obtain required prior authorization from correct vendor
- Document that prior authorization requirements were checked
Before January 1, 2027: Remove all "Recommended Clinical Review" optional request options from billing workflows and encounter forms, as this program is being phased out.
06Update internal guidelines to route previously-optional clinical review services to mandatory prior authorization instead.
07Retrain clinical and billing staff that Recommended Clinical Review will no longer be available as an option.
08Ongoing (All Dates): Implement system alerts requiring prior authorization verification for all genetic testing, oncology, orthotics, wound care, and DME codes before claim submission.
09Claims submitted without required prior authorization from the designated vendor will be denied, and the rendering provider may not seek reimbursement from the member.
10Maintain current vendor assignments as described in policy update notices.
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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