PAYER POLICY CHANGES

Illinois Medicaid Policy Changes

Policy changes from Illinois Medicaid - HFS and from Medicaid managed care plans in Illinois, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.

Humana · Effective Nov 5, 2026Medium impact
Foot Bath Medications (New)
Humana's new Medicaid pharmacy guidance (effective November 5, 2026) states that select medications such as budesonide, ciclopirox, clindamycin, fluocinonide, ketoconazole, linezolid, nystatin, and vancomycin, when dispensed for mixing into foot baths or soaks, are generally not medically necessary and may lack compendia or label support. Claims for these drugs submitted close together with other foot bath medication claims may reject with NCPDP error code 88 / internal code 527 ('Questionable compendia support'), and medications are approved only if label or compendia-supported use is shown on clinical review.
Humana · Effective Jan 1, 2020Medium impact
Non-Preferred Exceptions (Revised)
This is historical material (originally effective January 1, 2020, revised October 28, 2026) describing Humana's non-preferred exception procedure for Medicaid members in Florida, Illinois, South Carolina, and Virginia. The policy outlines how prescribers request exceptions to use non-preferred drugs, the required supporting documentation, and Humana's 24-hour decision timeline. The billing team should verify current applicability with Humana before acting on this guidance, as the discovery date (November 3, 2026) does not confirm whether this policy remains in effect.
Illinois Medicaid - HFS · Identified Oct 30, 2026Low impact
Tailored Care Management Program (TCMP) Webinar
The Illinois Department of Healthcare and Family Services is hosting an informational webinar on November 6, 2026, to introduce the Tailored Care Management Program (TCMP) administered by Telligen, Inc. for Williams and Colbert Class Members in specialized mental health and nursing facilities. This is a provider notice inviting CMHCs, CCBHCs, and BHCs to attend and learn about partnership and subcontracting opportunities; no billing workflow changes or coverage modifications are announced.
Humana · Effective Jan 1, 2019Medium impact
Antipsychotic Utilization Program (Revised)
This is a historical policy document (originally effective 2019-01-01, revised 2026-10-28) that establishes prior authorization requirements for atypical and typical antipsychotic medications when prescribed to members with dementia without appropriate clinical indication. The policy applies to Medicare and multiple state Medicaid programs (FL, IL, SC, IN, OK, VA) and outlines clinical approval criteria based on age, compendia-supported diagnoses, and behavioral severity. The billing team should verify current applicability through Humana's online policy portal rather than relying on this printed version.
Humana · Effective Jan 1, 2027High impact
Benzodiazepine Limited Days Supply (New)
Effective January 1, 2027, Humana Illinois Medicaid implements a new pharmacy coverage policy limiting initial benzodiazepine dispensing to a maximum 14-day supply for new users (no benzodiazepine claim in past 60 days), with prior authorization required for initial claims exceeding this limit. Subsequent fills after the initial dispensing follow standard renewal guidelines. This policy applies to 15 benzodiazepine medications across all formulations.
Molina Healthcare · Effective Oct 9, 2026Medium impact
October 26, 2026 - Medicaid Formulary PDL Changes, Fourth Quarter 2026
Molina Healthcare of Illinois updated its Medicaid Preferred Drug List (PDL) effective October 9, 2026, changing the formulary status of five injectable medications: Ebglyss, Skyrizi, Tremfya, Hadlima, and Adalimumab-ADBM. Four products moved to preferred status with prior authorization (PA) required; one product (Adalimumab-ADBM) moved to non-preferred status. Providers must replace non-preferred products with preferred alternatives on or after October 9, 2026, or submit a Pharmacy Prior Authorization form with clinical justification.
Humana · Effective Oct 28, 2026Medium impact
Minimally Invasive Sinonasal and Eustachian Tube Procedures - MEDICAID - ILLINOIS (New)
Humana Illinois Medicaid establishes new coverage criteria for minimally invasive sinonasal and Eustachian tube procedures. Balloon dilation of the Eustachian tube (BDET) is covered for adults 18+ with chronic obstructive ETD lasting >12 weeks despite management of contributing conditions, when supported by hearing evaluation, nasal endoscopy, and otoscopic examination. Posterior nasal nerve ablation procedures are NOT covered due to insufficient evidence.
Humana · Effective Oct 28, 2026Medium impact
Cardiac Devices - MEDICAID - ILLINOIS (New)
Humana Illinois Medicaid has established new coverage policy for Mobile Cardiac Outpatient Telemetry (MCOT) effective 2026-10-28. The policy covers real-time continuous attended cardiac monitoring (CPT 93228, 93229) for members with infrequent/unpredictable symptoms and either recurrent unexplained syncope with suspected arrhythmic etiology or suspected paroxysmal atrial fibrillation as cause of cryptogenic stroke. For members under age 21, medical necessity reviews must comply with EPSDT requirements.
Humana · Effective Oct 28, 2026High impact
Breast Procedures - MEDICAID - ILLINOIS (New)
Humana Illinois Medicaid has adopted a new breast procedures coverage policy (HUM-IL-2030-000) effective 2026-10-28, establishing medical necessity criteria for breast lesion excision, breast reconstruction, capsulotomy/capsulectomy, implant removal, and implant reinsertion. The policy specifies eligible diagnoses, surgical procedures, and CPT codes for coverage determination under Illinois Medicaid.
Humana · Effective Jan 1, 2020Medium impact
Previous Treatment/Prior Therapy/Trial (Revised)
This is historical guidance (originally effective 2020-01-01, most recently revised 2026-10-21) defining how Humana interprets 'Previous Treatment,' 'Trial,' and 'Prior Therapy' requirements in pharmacy coverage policies across Medicare and multiple state Medicaid programs. The policy clarifies that a single pharmacy claim (typically 28–30 days, or less for certain therapeutic classes) may satisfy prerequisite therapy documentation, unless a shorter timeframe is specified in drug-specific clinical policies. Members in their first 90 days of coverage are exempt from prerequisite therapy review. Billing teams should verify current applicability before applying this guidance to coverage determinations.
Humana · Effective Aug 28, 2010Medium impact
Drug Utilization Management and Clinical Edits Tools (Revised)
This is a historical pharmacy policy document from August 28, 2010, newly discovered on October 21, 2026. The policy establishes Humana's Drug Utilization Management (DUM) and clinical edits framework, including step therapy, quantity limits, prior authorization, accumulation edits, and duplication edits across Medicare and multiple state Medicaid programs. The document was revised on October 21, 2026, but no specific content changes from the original effective date are detailed in this version.
Humana · Effective Jan 1, 2017Low impact
Quantity Limitation (Revised)
This is a historical policy document from January 1, 2017 that was recently discovered (October 21, 2026). It establishes Humana's framework for pharmacy quantity limitations across Medicare and multiple state Medicaid programs. The policy permits quantity limits based on FDA-approved dosing, medical literature, and treatment guidelines, with exceptions available for dosage titration, compendia-supported dosages, failed trials, or individual member characteristics. The most recent revision is October 21, 2026, but no new effective date or changes are stated in this revision—verify current applicability with Humana's online policy portal.
Humana · Effective Jun 3, 2020Low impact
Non-FDA Approved Medications (Revised)
This is historical material from a Humana Medicaid pharmacy policy originally effective June 3, 2020, revised October 21, 2026. The policy establishes that non-FDA approved medications are excluded from Humana formularies unless reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. Coverage for approved non-FDA medications is limited to the plan year duration. No new actionable changes are indicated; verify current applicability with Humana before applying this guidance.
Illinois Medicaid - HFS · Effective Oct 1, 2027Medium impact
Supportive Living Program (SLP) Camera/Surveillance Policy
Illinois HFS requires Supportive Living Program providers to keep surveillance camera use rare, individually assessed, and thoroughly documented when privacy is limited, and never a default practice. Cameras may be used in non-resident operational spaces for basic building security or operational purposes, provided placement does not materially reduce resident privacy in HCBS service areas. Cameras are prohibited in resident dining, activity, and therapy rooms or comparable service areas, and in bathrooms, changing areas, and toileting areas under any circumstances, and audio monitoring in resident spaces is prohibited.
BCBS Illinois · Identified Oct 16, 2026Medium impact
View Reminders and Quick Tips for Medicaid Authorizations
Blue Cross and Blue Shield of Illinois launched Medicaid Authorizations, a new application within Availity Essentials in April 2026 for submitting and managing prior authorization and utilization management requests for Illinois Medicaid members. This document provides operational guidance and tips for providers who have not yet adopted the new application or need a refresher on its features and navigation.
BCBS Illinois · Effective Jan 1, 2027High impact
Managed Long-Term Services and Supports Transition for Blue Cross and Blue Shield of Illinois
Effective January 1, 2027, Blue Cross and Blue Shield of Illinois (BCBSIL) will cease providing Managed Long-Term Services and Supports (MLTSS) coverage. All current MLTSS members will be transitioned to Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) operated by awarded MLTSS Prepaid Inpatient Health Plan sponsors, with member reassignments coordinated by the Illinois Department of Healthcare and Family Services. Home and Community-Based Services waiver coverage for non-MLTSS members through Blue Cross Community Health Plans remains unchanged.
BCBS Illinois · Identified Oct 8, 2026Medium impact
Home Health and Homemaker Waiver Providers Must Register With HHAeXchange
Blue Cross Blue Shield Illinois is reminding contracted Home Health and Homemaker Waiver providers that they must register with HHAeXchange, Illinois' Electronic Visit Verification (EVV) system required by the Illinois Department of Healthcare and Family Services for Medicaid-funded in-home personal care and home health services. Providers can register with HHAeXchange at no cost or use an alternate EVV system that integrates with HHAeXchange.
BCBS Illinois · Identified Oct 8, 2026Low impact
Reach Out to Members to Close Care Gaps and Support Wellness
Blue Cross Blue Shield of Illinois is encouraging providers to conduct year-end outreach to members to close care gaps and support preventive wellness activities. This is an informational guidance document promoting proactive member engagement around HEDIS measures, preventive screenings, immunizations, and chronic disease management before year-end, with resources available to support outreach efforts.
Illinois Medicaid - HFS · Identified Oct 7, 2026Low impact
Publicly Owned Transportation Providers – Ground Emergency Medical Transportation (GEMT) Supplemental Payments
This notice informs publicly owned transportation providers enrolled in the Ground Emergency Medical Transportation (GEMT) program that supplemental payments for Fiscal Year 2026, Quarter 4 (April 1–June 30, 2026) must be submitted by October 31, 2026. The preferred payment method is ACH Direct Debit; checks are accepted as an alternative.
Illinois Medicaid - HFS · Effective Oct 13, 2026Medium impact
Federal Rule on Gender Affirming Care for Young People
Effective October 13, 2026, a new federal rule restricts Medicaid coverage of gender affirming care for youth. Illinois HFS will bridge the coverage gap using state-only funds through the end of state fiscal year 2027 (June 30, 2027), with future funding decisions deferred to the budget process. Billing teams must continue following existing billing instructions while HFS handles federal compliance on the back end by not claiming federal matching dollars on affected claims.
Illinois Medicaid - HFS · Effective Oct 1, 2026Medium impact
Upcoming Respiratory Syncytial Viral (RSV) Season
This provider notice confirms continued Medicaid coverage (both FFS and MCOs) for RSV immunizations during the 2026-2027 RSV season (October 1 through March 31). Coverage includes monoclonal antibodies (Beyfortus and Enflonsia) for eligible infants under 8 months, Beyfortus for high-risk children 8-19 months, maternal RSV vaccine (Abrysvo) for pregnant individuals at 32-36 weeks gestation, and adult RSV vaccines (Abrysvo, mResvia, Arexvy) for seniors 75+ and specified high-risk populations. Prior authorization is not required for these covered immunizations.
Illinois Medicaid - HFS · Effective Oct 1, 2007Low impact
Prior Approval Required for Non-Emergency Transportation for Long Term Care Residents
Effective October 1, 2007, long-term care (LTC) facility residents were added to the Non-Emergency Transportation Services Prior Approval Program (NETSPAP), requiring prior approval before billing for non-emergency transportation services. This is historical material from 2007 newly discovered in 2026; current applicability must be verified with the Illinois Department of Financial and Professional Regulation (successor to HFS).
Illinois Medicaid - HFS · Identified Oct 6, 2026High impact
Updated Provider Revalidation Cycle
The Illinois Department of Healthcare and Family Services (HFS) has implemented a more frequent provider revalidation requirement mandated by CMS. High-risk providers, providers without an NPI, laboratory providers, and ABA providers must now complete revalidation within a two-year cycle instead of the previous five-year cycle. Providers who revalidated or newly enrolled between April 30, 2025 and April 30, 2026 are exempt from this accelerated timeline.
BCBS Illinois · Effective Oct 2, 2026High impact
Reminder: We’ll Conduct Postpayment Reviews on Medicaid Claims
Beginning October 2, 2026, the payer will conduct postpayment reviews of Medicaid member claims to identify billing inconsistencies, coding errors, and reimbursement policy alignment issues. Reviews will apply to claims paid on or after January 1, 2026, current claims, and prospective claims. The payer may request refunds or adjust future payments based on findings if documentation does not support submitted claims.
Illinois Medicaid - HFS · Effective Jan 1, 2027Low impact
Federal Fiscal Year 2027 Safety Net Determination
This is an informational notice from the Illinois Department of Financial and Professional Regulation regarding the annual Federal Fiscal Year 2027 Safety Net Determination for enrolled hospitals. The safety net status determination results are now available on the Department's website and are effective January 1, 2027 through December 31, 2027. Billing teams should verify their hospital's safety net status designation for 2027.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
BCBS Illinois · Effective Oct 1, 2026High impact
Prior Authorization Changes for Some Commercial and Government Program Members
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.
Illinois Medicaid - HFS · Identified Oct 1, 2026Low impact
Directed Payment Calculations on Website
The Illinois Department of Financial and Professional Regulation has posted directed payment calculations for October through December 2026 on the Hospital Reimbursement Notifications Website. Hospitals should access the 'Directed Payment and Passthrough Reports' section to review their quarterly directed payment amounts. New reports will be posted quarterly as required by Public Act.
BCBS Illinois · Effective Jan 1, 2027High impact
Pharmacy Program Updates: Prior Authorization Changes Effective Jan. 1, 2027
Effective January 1, 2027, Blue Cross Blue Shield of Illinois (administered through Prime Therapeutics) is updating prior authorization criteria for 16 pharmacy programs covering specialty medications across multiple therapeutic categories including biologics, immunomodulators, oncology agents, and rare disease treatments. Two new prior authorization programs are also being introduced (Hepatitis D and Nereus). All changes affect multiple plan types across Illinois and require billing teams to implement updated PA requirements in their systems.
BCBS Illinois · Identified Sep 29, 2026Low impact
Encourage Pregnant Members With BCCHPSM To Sign Up for Special Beginnings® Program
Blue Cross Community Health Plans (BCCHP) is promoting enrollment in the Special Beginnings® maternity care management program for pregnant members. Providers should encourage eligible pregnant members to enroll via the helpline (888-421-7781) or online rewards form, and indicate pregnancy status when submitting prior authorization requests through Availity Essentials to ensure members receive appropriate pregnancy support services.
Illinois Medicaid - HFS · Effective Aug 25, 2026High impact
Fiscal Year 2026 and 2027 Managed Care Organization Provider Assessment Program Tier Rate Re-Assessment Notice
Illinois Department of Human Services has re-assessed Managed Care Organization (MCO) provider assessment fees for fiscal years 2026 and 2027 using updated 2023 member month data and newly including FIDE SNP member months. Tax tier rates have been adjusted, with FY2026 Tier 1 at $115.00 per member month and FY2027 Tier 1 at $116.90 per member month. Any over- or underpayments from the initial assessment have been recalculated and will be distributed across remaining FY2027 monthly installment payments beginning October 2026.
Illinois Medicaid - HFS · Identified Sep 29, 2026Low impact
Home Care Program Evaluation Surveys
The Illinois Department of Healthcare and Family Services (HFS) is conducting a mandated evaluation of the Home Care Program (MFTD Waiver and Non-Waiver programs) and requesting home nursing agencies, families, and direct care nurses to complete stakeholder surveys by specific deadlines. Surveys will be distributed starting October 1, 2026, with a November 30, 2026 deadline for agencies and 60-day windows for families and nurses. This is an informational and compliance notice; billing teams should be aware that affiliated home nursing agencies may need to allocate resources to complete the required survey.
BCBS Illinois · Effective Jan 1, 2027High impact
Use Medicaid ID Instead of Subscriber ID for Members with BCCHPSM
Effective January 1, 2027, Blue Cross Community Health Plans (BCCHP) members in Illinois will use their Medicaid ID (9-digit recipient identification number) instead of the BCBSIL subscriber ID for all healthcare transactions. The subscriber ID will no longer be accepted. Providers must update systems and processes to capture, store, and submit the Medicaid ID for eligibility checks, prior authorizations, claim submissions, and customer service inquiries.
Illinois Medicaid - HFS · Effective Jan 1, 2027Medium impact
2027 Critical Access Pharmacy (CAP) Program
Illinois Department of Healthcare and Family Services (HFS) is establishing a 2027 Critical Access Pharmacy (CAP) Program that provides enhanced dispensing fee payments to eligible independent pharmacies. Pharmacies must meet specific ownership, location, and prescription volume criteria and complete online attestation between October 1-31, 2026, to qualify for Calendar Year 2027 benefits.
BCBS Illinois · Effective Jan 1, 2027High impact
New Digital Interfaces To Simplify Prior Authorization Requests
Effective January 1, 2027, a major insurance carrier will launch new digital APIs to streamline prior authorization requests for Medicare Advantage, Medicaid, and select commercial members. The APIs will enable real-time prior auth status tracking, simplified determination of authorization requirements, and direct access to patient data (prior auth status, encounter data, claims data) through your EHR system, significantly reducing administrative burden.
BCBS Illinois · Identified Sep 24, 2026Low impact
Discuss Oral Hygiene as Part of Preventive Care for Children with Medicaid
This is an informational update from Blue Cross Blue Shield of Illinois reminding providers about existing Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program requirements for Medicaid-enrolled children, including mandatory oral health risk assessments at 6 and 9 months of age and referral to dental care by age 1. No new billing codes, coverage changes, or effective date requirements are introduced—this is educational reinforcement of established EPSDT guidelines and HEDIS quality measures.
Illinois Medicaid - HFS · Identified Sep 24, 2026Medium impact
ICF/IID and MC/DD Facility Provider – Acuity Data Request
The Illinois Department of Healthcare and Family Services is requiring all ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities) and MC/DD (Medically Complex for the Developmentally Disabled) facility providers to submit individual-level acuity data (ICAP and HRST) by October 23, 2026, as part of a program evaluation. Providers must register users and submit data via a new LTC Exchange SharePoint portal by specific deadlines.
Illinois Medicaid - HFS · Effective Jul 1, 2026Medium impact
Stuttering Coverage
Illinois Department of Healthcare and Family Services (HFS) now covers medically necessary habilitative services for early-acquired speech-language disorders, including stuttering, for children under age 21 through Medicaid fee-for-service and HealthChoice Illinois managed care organizations. This coverage became effective July 1, 2026, and is mandated by Public Act 104-0528. The policy also confirms that rehabilitative services for stuttering were already covered under prior guidance.
Humana · Effective Jan 1, 2022High impact
Anticholinergic Polypharmacy Agents (Revised)
Humana implemented a safety edit for anticholinergic polypharmacy (concurrent use of 2+ anticholinergic medications) in members age 65+. Approval now requires provider attestation that benefits outweigh risks of falls, fractures, cognitive decline, and delirium per AGS Beers Criteria 2023. Members in hospice are exempt from this requirement. This guidance applies across Medicare and multiple state Medicaid programs.
BCBS Illinois · Identified Sep 22, 2026Medium impact
Encourage Routine Screening to Detect Breast Cancer Early
Blue Cross Blue Shield of Illinois issued guidance to providers emphasizing routine breast cancer screening beginning at age 40 with screenings every other year until age 74, per USPSTF guidelines. The policy includes specific documentation, coding, and quality measure tracking requirements for breast cancer screening encounters, with emphasis on closing care gaps and addressing disparities in screening rates among Black women.
Illinois Medicaid - HFS · Identified Sep 22, 2026Medium impact
Distribution of Fiscal Year 2027 Disproportionate Share Hospital (DSH) Determination
This is a clarification notice correcting an error in the FY 2027 DSH Determination letters. The appeal deadline was incorrectly stated as Saturday, October 19, 2026, and has been corrected to Monday, October 19, 2026. Hospitals must ensure appeals are submitted by the correct date to avoid missing the deadline.
BCBS Illinois · Identified Sep 18, 2026Low impact
Support Care Coordination After Hospital Discharges
This is a care coordination guidance policy (not a billing rule change) emphasizing the importance of timely hospital discharge summaries and follow-up care between hospital and primary care teams. It provides recommendations for hospitals and PCPs to improve care transitions and reduce readmissions, but does not establish new billing requirements, coding changes, or coverage determinations.
BCBS Illinois · Effective Jan 1, 2027Medium impact
Illinois House Bill Aims to Increase In-Network Options for MH/SUD Services, Effective Jan. 1, 2027
Illinois House Bill 1085 (Public Act 104-0446) simplifies network participation for mental health and substance use disorder (MH/SUD) providers effective January 1, 2027. The legislation impacts reimbursement rates, network enrollment timelines, how MH/SUD services are reimbursed, and coverage for behavioral health trainees. Billing teams should monitor for reimbursement rate changes and updated network participation requirements.
Illinois Medicaid - HFS · Effective Oct 1, 2026High impact
Coverage of Wegovy for MACE and MASH, and Zepbound for OSA
Effective October 1, 2026, Illinois Medicaid (both FFS and Managed Care) will cover Wegovy (semaglutide tablets and injection) for MACE reduction in adults with established cardiovascular disease and obesity/overweight, and for MASH treatment with moderate-to-advanced liver fibrosis (F2-F3). Zepbound (tirzepatide) is now covered for moderate-to-severe obstructive sleep apnea in adults with obesity. All three indications require prior authorization. Weight loss alone remains non-covered.
Illinois Medicaid - HFS · Effective Jul 1, 2026Low impact
Calendar Year Safety Net Obstetrical Payment Program – July 1, 2026 – September 30th, 2026
The Illinois Department of Financial and Professional Regulation has posted Calendar Year 2026 Safety Net Obstetrical Payment Program calculations for the period July 1 – September 30, 2026. This program distributes $50M annually to qualifying safety-net hospitals to preserve or enhance OB/GYN and specialty services. Enrolled hospitals should access the posted calculations and payments files to verify their allocations.
Illinois Medicaid - HFS · Identified Sep 9, 2026High impact
Federal Changes to Medicaid Eligibility
Illinois Department of Healthcare and Family Services announces two major Medicaid eligibility changes: (1) Federal law eliminates Medicaid coverage for most lawfully present noncitizens effective October 1, 2026, with limited exceptions for green card holders, certain entrants from Cuba/Haiti, COFA migrants, and children under 19 and pregnant women; (2) New federal work requirements for ACA Adults (ages 19-64 with income up to 138% FPL) effective January 1, 2027, with specific exemptions for medically frail, caregivers, veterans, pregnant women, foster youth, and others. Billing teams must identify affected patient populations and implement eligibility verification procedures before both dates.
BCBS Illinois · Identified Sep 5, 2026High impact
Medicaid Reminder: Know When To Request Post Acute Care Authorizations
Blue Cross Community Health Plans (BCCHP) Medicaid now requires providers to request prior authorization for post-acute care facility admissions no more than three days prior to admission, rather than earlier timeframes. This change reflects the plan's requirement to account for rapidly changing health conditions and medical necessity. Billing teams must update their prior authorization submission workflows to align with this three-day window.
Illinois Medicaid - HFS · Identified Sep 5, 2026High impact
Dental Office Reference Manual – Reissue; Exhibits A-C Dental Benefits Covered Coding Updates
Illinois Department of Financial and Professional Regulation has reissued the Dental Office Reference Manual (DORM) with updates to dental benefits covered coding. Providers must review the updated DORM and Exhibits A-C for coding changes to ensure accurate billing and payment from the Department.
UnitedHealthcare · Identified Sep 2, 2026High impact
Hereditary cancer testing policy reminder
UnitedHealthcare is reminding providers that multigene RNA panel testing for hereditary cancer is considered unproven and will be denied. Only DNA-only hereditary cancer panels and single-gene RNA testing remain covered under applicable medical policy and prior authorization requirements.
Illinois Medicaid - HFS · Identified Sep 2, 2026Medium impact
Home and Community-Based Service (HCBS) Requirements for the Illinois Supportive Living Program (SLP)
Illinois Supportive Living Program providers operate under the federal 1915(c) HCBS Medicaid Waiver and must meet HCBS settings requirements. Residents must be educated on their right to control their own income and resources, including choosing a representative payee and using their personal needs allowance as they wish, and SLP staff cannot force incoming residents to assign the SLP provider as representative payee. SLPs must also support residents in seeking employment and working in competitive integrated settings, and the survey questions for these requirements apply to all SLPs effective October 2026.

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Foot Bath Medications (New)

Non-Preferred Exceptions (Revised)

Tailored Care Management Program (TCMP) Webinar

Antipsychotic Utilization Program (Revised)

Benzodiazepine Limited Days Supply (New)

October 26, 2026 - Medicaid Formulary PDL Changes, Fourth Quarter 2026

Minimally Invasive Sinonasal and Eustachian Tube Procedures - MEDICAID - ILLINOIS (New)

Cardiac Devices - MEDICAID - ILLINOIS (New)

Breast Procedures - MEDICAID - ILLINOIS (New)

Previous Treatment/Prior Therapy/Trial (Revised)

Drug Utilization Management and Clinical Edits Tools (Revised)

Quantity Limitation (Revised)

Non-FDA Approved Medications (Revised)

Supportive Living Program (SLP) Camera/Surveillance Policy

View Reminders and Quick Tips for Medicaid Authorizations

Managed Long-Term Services and Supports Transition for Blue Cross and Blue Shield of Illinois

Home Health and Homemaker Waiver Providers Must Register With HHAeXchange

Reach Out to Members to Close Care Gaps and Support Wellness

Publicly Owned Transportation Providers – Ground Emergency Medical Transportation (GEMT) Supplemental Payments

Federal Rule on Gender Affirming Care for Young People

Upcoming Respiratory Syncytial Viral (RSV) Season

Prior Approval Required for Non-Emergency Transportation for Long Term Care Residents

Updated Provider Revalidation Cycle

Reminder: We’ll Conduct Postpayment Reviews on Medicaid Claims

Federal Fiscal Year 2027 Safety Net Determination

New oncology prior authorization code updates

Prior Authorization Changes for Some Commercial and Government Program Members

Directed Payment Calculations on Website

Pharmacy Program Updates: Prior Authorization Changes Effective Jan. 1, 2027

Encourage Pregnant Members With BCCHPSM To Sign Up for Special Beginnings® Program

Fiscal Year 2026 and 2027 Managed Care Organization Provider Assessment Program Tier Rate Re-Assessment Notice

Home Care Program Evaluation Surveys

Use Medicaid ID Instead of Subscriber ID for Members with BCCHPSM

2027 Critical Access Pharmacy (CAP) Program

New Digital Interfaces To Simplify Prior Authorization Requests

Discuss Oral Hygiene as Part of Preventive Care for Children with Medicaid

ICF/IID and MC/DD Facility Provider – Acuity Data Request

Stuttering Coverage

Anticholinergic Polypharmacy Agents (Revised)

Encourage Routine Screening to Detect Breast Cancer Early

Distribution of Fiscal Year 2027 Disproportionate Share Hospital (DSH) Determination

Support Care Coordination After Hospital Discharges

Illinois House Bill Aims to Increase In-Network Options for MH/SUD Services, Effective Jan. 1, 2027

Coverage of Wegovy for MACE and MASH, and Zepbound for OSA

Calendar Year Safety Net Obstetrical Payment Program – July 1, 2026 – September 30th, 2026

Federal Changes to Medicaid Eligibility

Medicaid Reminder: Know When To Request Post Acute Care Authorizations

Dental Office Reference Manual – Reissue; Exhibits A-C Dental Benefits Covered Coding Updates

Hereditary cancer testing policy reminder

Home and Community-Based Service (HCBS) Requirements for the Illinois Supportive Living Program (SLP)