Attend a Webinar to Prepare for Medicaid Prior Authorization Vendor Transition, Effective Aug. 1, 2025

May 1, 2025

We’re making changes affecting prior authorization requests for members with Blue Cross Community Health Plans^SM.

What’s changing: Effective Aug. 1, 2025, Carelon Medical Benefits Management will replace eviCore for prior authorization requests. Some prior authorization requests previously reviewed by eviCore will now be reviewed by Carelon or Blue Cross and Blue Shield of Illinois. First-level appeal reviews will move from eviCore to BCBSIL. Sign up for a webinar below to learn more about Carelon.

These changes do not apply to prior authorization for services for members of Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM.

Effective for dates of service on or after Aug. 1, 2025, prior authorization requests should be submitted to Carelon for the following care categories:

Genetic testing
Medical oncology
Radiation oncology
Musculoskeletal (spine, joint and pain procedures)
Radiology
Rehabilitation (physical, occupational and speech therapy)

Effective for dates of service on or after Aug. 1, 2025, prior authorization requests should be submitted to BCBSIL for some services in the following care categories:

Select lab services
Select radiology services
Chiropractic 
Post-acute care
Sleep

Refer to our website for details on how to submit prior authorization requests for review by BCBSIL. For a list of codes for services in each category where prior authorization is required for BCCHP^SM, see our prior authorization support materials (government programs).

What’s not changing? 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.

How to submit prior authorization requests through Carelon for BCCHP: Beginning July 14, 2025, contact Carelon for prior authorization requests for dates of service on or after 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.

You must register with Carelon to access their online portal. If you’re already registered with Carelon to submit prior authorization requests for our commercial members, you don’t need to register again for BCCHP.

Sign up now for a webinar to learn more about Carelon: We encourage all staff (physicians, APRNs, PAs, nurses, office managers, billing and coding staff) to participate in at least one training opportunity, even if you’re already familiar with Carelon. These live webinar sessions will demonstrate how to register and navigate the Carelon portal to enter prior authorization requests specific to our members with BCCHP. You’ll also learn where to find related resources, such as order entry checklists and clinical guidelines. Each session includes time for open discussion and Q&A.

Carelon Provider Training for Medicaid Prior Authorization Requests Register now by selecting your preferred date and time from the list below.
Genetic Testing	June 26 – noon to 1 p.m. July 9 – noon to 1 p.m.
Medical Oncology	June 26 – noon to 1 p.m. July 9 – 10 to 11 a.m.
Radiation Oncology	June 26 – 1 to 2 p.m. July 9 – 11 a.m. to noon
Musculoskeletal	June 26 – 2 to 3 p.m. July 10 – 2 to 3 p.m.
Radiology	June 18 – 2 to 3 p.m. July 9 – 2 to 3 p.m.
Rehabilitation (PT, OT, ST)	May 28 – 10 to 11:30 a.m. June 11 – 10 to 11:30 a.m. June 25 – 10 to 11:30 a.m. July 9 – 10 to 11:30 a.m.

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. 

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 (formerly AIM Specialty Health) 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. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.