Prior Authorization

What is prior authorization?

Prior authorization is a preservice utilization management review. Prior authorization is required for some members, services and drugs before services are rendered to confirm medical necessity as defined by the member’s health benefit plan. A prior authorization is not a guarantee of benefits or payment. The terms of the member’s plan control the available benefits.

Who requests prior authorization?

Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. Sometimes, a plan may require the member to request prior authorization for services. Information for members with commercial Blue Cross and Blue Shield of Illinois plans is found on our member site. Members with Blue Cross Community Health Plans^SM can visit the member site for BCCHP^SM.

Most out-of-network services require utilization management review. If the provider or member doesn’t get prior authorization for out-of-network services, the claim may be denied. Emergency services are an exception.

Why obtain a prior authorization?

If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:

The service or drug may not be covered, and the ordering or servicing provider will be responsible.
We may conduct a post-service utilization management review, which may include requesting medical records and reviewing claims for consistency with medical policies; clinical payment and coding policies; and accuracy of payment.
For Medicare and Medicaid members, if you don’t get prior authorization for services or drugs on our prior authorization lists, we won’t reimburse you, and you cannot bill our members for those services or drugs.

When and how should prior authorization requests be submitted?

In general, there are three steps providers should follow.

Step 1 – Confirm if Prior Authorization is Required

Remember, member benefits and review requirements will vary based on service/drug being rendered and individual/group policy elections. Always check eligibility and benefits first, via the Availity^® Essentials or your preferred web vendor, prior to rendering care and services. In addition to verifying membership/coverage status and other important details, this step returns information on prior authorization requirements and utilization management vendors, if applicable.

Checking eligibility and benefits is key, but we also have other resources to help you prepare. View our requirements summaries and procedure code lists for commercial and government programs for more details.

Step 2 – If prior authorization is required, have the following information ready:

Patient ID, name and date of birth
Patient’s medical or behavioral health condition
Proposed treatment plan
Date of service, estimated length of stay (if the patient is being admitted)
Place of treatment
Provider name, address and National Provider Identifier (NPI)
Diagnosis code(s)
Procedure code(s), if applicable

Step 3 – Submit Your Prior Authorization Request

Some requests are handled by BCBSIL and others are handled by utilization management vendors. Checking eligibility and benefits confirms if prior authorization is required and directs you to the appropriate vendor, if applicable.

For prior authorization requests handled by BCBSIL:

Online – For commercial non-HMO members only, use BlueApprovR^SM to request prior authorization for some services.
Online – For all members, registered Availity users may use Availity’s Authorizations tool (HIPAA-standard 278 transaction).
By phone – Call the prior authorization number on the member’s ID card.

Commercial non-HMO prior authorization requests handled by Carelon Medical Benefits Management

Online – The Carelon Provider Portal is available 24x7.
Phone – Call the Carelon Contact Center at 866-455-8415, Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a.m. to noon, CT on weekends and holidays.

Government programs prior authorization requests handled by EviCore healthcare:
This information applies to prior authorization requests for our members with these plans: Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM. View vendor transition details for BCCHP, effective Aug. 1, 2025.

Online – The EviCore Web Portal is available 24x7.
Phone – Call EviCore toll-free at 855-252-1117, Monday through Friday, 7 a.m. to 7 p.m., CT, except holidays.

Government programs (Medicaid) prior authorization requests handled by Carelon:
For members with BCCHP, Carelon will begin processing requests as of July 14, 2025, for dates of service beginning Aug. 1, 2025.

Online – The Carelon Provider Portal is available 24/7
Phone – Call Carelon at 866-455-8415, Monday through Friday, 7 a.m. to 7 p.m., CT

What happens next?

Once a prior authorization request is received and processed, the decision is communicated to the provider. Review your determination letter for details and instructions. If you have questions on a request handled by Carelon or EviCore, call the appropriate vendor. If you have questions on a request handled by BCBSIL, contact our Medical Management department.

Medical Management for BCBSIL

Commercial (non-HMO) – 800-572-3089
Government Programs – 877-774-8592 (MA PPO); 877-860-2837 (BCCHP); 877-723-7702 (MMAI)

Exceptions and Reminders

Commercial Performance and Exception Based UM Program (Gold Carding Program) – BCBSIL is waiving certain medical necessity review prior authorization requirements for select inpatient services for those acute care facilities that have consistently exceeded prior authorization performance and quality criteria. The criteria evaluate facility providers on certain UM metrics against national benchmark and other key indicators updated yearly. These high-performing acute care facility providers may be eligible to receive automatic approval of up to three days for select prior authorization requests. This program excludes government and administrative service contracts.
The prior authorization information in this section does not apply to services for our HMO members. For these members, prior authorization is handled by the medical group or independent practice association. 
For behavioral health services, there may be special instructions, forms or steps to consider. See the Behavioral Health Program section for details.
If pharmacy prior authorization program review through Prime Therapeutics is required, physicians may submit the uniform PA form.
For out-of-area (BlueCard^® program) members, if prior authorization is required, use the online router tool. It will redirect you to preservice review information on the member’s home plan website. For electronic provider access details, refer to the BlueCard Program Provider Manual .

Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Certain employer groups may require prior authorization or pre-notification through other vendors. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. 

Availity is a trademark of Availity, LLC., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. Carelon Medical Benefits Management is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. EviCore healthcare (EviCore) is an independent company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products or services they offer.

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