Transition to Carelon for Medicaid Prior Authorization Requests

July 28, 2025

We’ve made changes affecting prior authorization requests for members with Blue Cross Community Health PlansSM. These changes don’t 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, some prior authorization requests previously reviewed by Evicore healthcare will now be reviewed by Carelon or Blue Cross and Blue Shield of Illinois. First-level appeal reviews for BCCHPSM have moved from Evicore to BCBSIL. 

Submitting requests to Carelon
Prior authorization requests should be submitted to Carelon for these care categories:

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

There are two ways you can submit your request:

Submitting requests to BCBSIL
Prior authorization requests should be submitted to BCBSIL for some services in these 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 a list of service codes in each category where prior authorization is required for BCCHP, see prior authorization support materials (government programs).

Reminders and resources
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.

Learn more about Carelon. Follow these steps to access on-demand training:

  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 (Rehabilitation)
  • Medical Oncology

Continue to watch News and Updates for more information on program enhancements for BCCHP and other initiatives.

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 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.