Prior Authorization Changes for Some Government Program Members

Oct. 30, 2026

We’re changing prior authorization requirements that may apply to some government program members.

Changes are based on updates from 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 Medicare & Medicaid 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 Medicare Advantage members will be reviewed by BCBSIL. Carelon Medical Benefits Management will review utilization management and related services for some commercial members and those with Blue Cross Community Health Plans^SM.

Note: Effective Jan. 1, 2027, we will begin reducing recommendations that you complete a Recommended Clinical Review. We expect to remove this option entirely from our utilization management processes by the end of 2027. Learn more about this utilization management program change for commercial members.

Review the upcoming changes by impacted members and effective dates below.

Medicare Advantage – Dec. 21, 2026:

Removal of proprietary laboratory analyses, drugs and biologics, molecular pathology/genetics, infectious disease molecular testing, radiology and advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, ophthalmology, miscellaneous specialty procedure codes previously reviewed by BCBSIL

Reminder: As previously communicated in our News and Updates, the following changes for members of Medicare Advantage will begin:

Jan. 1, 2027:

Addition of oncology drug, orthotics, wound care and durable medical equipment codes to be reviewed by BCBSIL
Miscellaneous changes to the Part B Step Therapy Program

For more information and code lists, including summary lists of recent changes, 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.

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. 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.