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Prior Authorization Changes for Some Government Program Members
Effective date
Not stated in the notice
Identified
Oct 31, 2026
Summary
Blue Cross Blue Shield of Illinois is removing prior authorization requirements for multiple specialty procedure codes for Medicare Advantage members effective Dec. 21, 2026, while simultaneously adding new codes (oncology drugs, orthotics, wound care, and durable medical equipment) to require prior authorization effective Jan. 1, 2027. Additionally, the plan is phasing out the Recommended Clinical Review option, with reductions beginning Jan. 1, 2027 and complete removal expected by end of 2027.
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What to do
Action · 7 steps
01By Dec.
0221, 2026: Billing team should update prior authorization workflows to remove authorization requirements for proprietary laboratory analyses, drugs and biologics, molecular pathology/genetics, infectious disease molecular testing, radiology and advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, and ophthalmology procedures for Medicare Advantage members.
03By Jan.
041, 2027: Billing team should implement prior authorization requirements for oncology drug, orthotics, wound care, and durable medical equipment codes for Medicare Advantage members reviewed by BCBSIL.
05Additionally, update billing system and provider encounter forms to reflect that Recommended Clinical Review requests are being phased out and will no longer be available by end of 2027.
06Providers must continue checking eligibility and benefits through Availity Essentials prior to rendering services to confirm current prior authorization requirements.
07Note: Claims for services performed without required prior authorization or not meeting medical necessity criteria will be denied, and rendering providers may not seek reimbursement from members.
Original notice
Prior Authorization Changes for Some Government Program Members
bcbsil.com · Always check the source before changing claims.