Oct. 22, 2025
In August 2025, we transitioned review of some prior authorization requests for our members with Blue Cross Community Health PlansSM to Carelon Medical Benefits Management, including requests for genetic testing, medical oncology, radiation oncology, musculoskeletal (spine, joint and pain procedures), radiology and rehabilitation (physical, occupational and speech therapy).
This notice includes an important reminder for rehabilitation (PT, OT, ST) prior authorization requests submitted to Carelon for review.
Maximum quantity is defined in units: Carelon authorizes rehabilitation services in units, following the Illinois Department of Healthcare and Family Services therapy fee schedule. The HFS fee schedule defines maximum quantity as follows: “The maximum number of units billable for the procedure code. A Max Qty greater than '1' indicates the code is billable in 15-min increments. In these instances, 1 unit = one 15-min increment.”
Why it matters: When you submit a prior authorization request for review of rehabilitation (PT, OT, ST) services for members with BCCHPSM, the response you receive from Carelon will reflect approval of care in units, not number of visits.
Learn more about how to submit requests to Carelon: Follow the steps below to access on-demand training for rehabilitation and other care categories.
1. Log on to the Carelon portal
2. Select the Help Desk icon
3. Select the Tutorials icon and choose from these on-demand training sessions:
- Advanced Imaging/Cardiology
- Genetic Testing
- Joint/Spine Management and Pain Management
- Radiation Therapy
- MSK Therapies (includes Rehabilitation)
- Medical Oncology
Always check eligibility and benefits first: Prior to rendering care and services for members with BCCHP, check eligibility and benefits through Availity® Essentials or your preferred vendor portal. This step helps confirm if prior authorization is required for a specific service and member. You’ll also be directed to the appropriate utilization management vendor, if applicable, to submit your request for review.
Carelon Medical Benefits Management (formerly AIM Specialty Health) is an independent company that has contracted with Blue Cross and Blue Shield of Illinois to provide utilization management services for members with coverage through BCBSIL. 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. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider.