June 27, 2024
We’re changing prior authorization requirements that may apply to some commercial non-HMO 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 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 some commercial non-HMO members will be reviewed by Carelon Medical Benefits Management.
Here is a summary of changes, effective Oct. 1, 2025:
- Addition of sleep codes to be reviewed by Carelon
- Addition of genetic testing codes to be reviewed by Carelon
- Addition of a musculoskeletal code to be reviewed by Carelon
- Replacement of medical oncology drug codes to be reviewed by Carelon
- Addition of medical oncology codes to be reviewed by Carelon
- Removal of a drug therapy code previously reviewed by BCBSIL
- Addition of various drug codes to be reviewed by BCBSIL
For more information, refer to utilization management. See support materials (commercial) for updated procedure code lists.
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 for a commercial non-HMO member, you still may want to submit a voluntary recommended clinical review request. This step can help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request recommended clinical review, since it’s optional. Refer to our medical policy reference list 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 AMA. 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.
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.