Oct. 1, 2025
We’re changing prior authorization requirements that may apply to some commercial non-HMO members and members with Blue Cross Medicare Advantage (PPO)SM, Blue Cross Community Health PlansSM or Blue Cross Community MMAI (Medicare-Medicaid Plan)SM.
Changes are based on utilization management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System code changes from the Centers for Medicaid & Medicare Services.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Illinois. Utilization management and related services for MMAISM and Medicare Advantage members will be reviewed by EviCore healthcare. Carelon Medical Benefits Management will review utilization management and related services for some commercial members and those with BCCHPSM.
These changes for commercial members begin Jan. 1, 2026:
- Addition of Advanced Imaging codes to be reviewed by Carelon
- Addition of Sleep codes to be reviewed by Carelon
- Addition of Genetic Testing codes to be reviewed by Carelon
These changes for members of government programs begin Jan. 1, 2026:
- Addition of Specialty Drug codes to be reviewed by EviCore (MA, MMAI)
- Addition of Molecular Genetic Lab Testing codes to be reviewed by EviCore (MA)
- Addition of specialized Radiological codes to be reviewed by Carelon (BCCHP)
- Removal of Early and Periodic Screening, Diagnostic and Treatment codes previously reviewed by BCBSIL (BCCHP)
- Replacement of Specialty Oncological Drug codes reviewed by BCBSIL (BCCHP)
Note: after annual review there are additional changes coming Jan. 1, 2026, across many categories for Medicare Advantage. See the prior authorization code list for specific changes.
For more information and code lists, refer to utilization management.
Always check eligibility and benefits first through Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Even if prior authorization isn’t required, you still may want to submit a voluntary recommended clinical review request. This step can help avoid postservice medical necessity review. Checking eligibility and benefits can’t tell you when to request recommended clinical review, since it’s optional. But there’s a medical policy reference list on our recommended clinical review page to help you decide.
Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
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. If you have any questions, call the number on the member's ID card.
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. EviCore Healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.