Acquisition of Cigna Healthcare Medicare Business in 2025

No changes to member benefits will happen in 2025. More information about future changes will be communicated here. Read more details about the transaction.

Utilization Management Expanding to Include Site of Care Review of Advanced Imaging for Some Commercial Members

Effective Jan. 1, 2025, Carelon will review requests for authorization for some advanced imaging services in a hospital‑based outpatient setting. They will determine if a hospital setting is medically necessary and redirect the service to a freestanding alternative, if applicable.

Some Commercial Members Will Receive Vaginal Estrogen Coverage

Under this benefit expansion, effective Jan. 1, 2025, member cost sharing for vaginal estrogen cream will be at the same level as cost sharing for covered prescription erectile dysfunction medications. Prescriptions for these medications must be filled at an in‑network pharmacy to qualify for the cost‑sharing requirement.

Fraud, Waste and Abuse Reminder: Accurately Identify Rendering Provider for Properly Paid Claims

Reimbursement for claims is based on the type of rendering provider indicated on the claim. Please ensure claim submissions comply with requirements specified in our Provider Manual and your provider agreement.

Use the Updated Claims Referral Form for American Indian/Alaska Native Limited Cost-Share Plans

Faxing is no longer an option for pharmacy referrals, so we’ve updated the claims referral form that Indian Health, Tribal and Urban Indian providers use to refer members of limited cost‑sharing plans to non‑I/T/U providers.

Submit Paper Commercial Claims to Correct PO Box to Avoid Delays

We announced address changes last year for faster claims processing and responses. To avoid mail processing delays, submit paper commercial claims – including CMS‑1500 and UB‑04 forms – to the correct address.

Procedure Code and Fee Schedule Updates

On Jan. 1, 2025, we’ll implement Current Procedural Terminology (CPT^®) and Healthcare Common Procedure Coding System procedure code additions, deletions and revisions.

ClaimsXten^TM Quarterly Update

We’ll implement fourth‑quarter code updates for the ClaimsXten auditing tool on or after Dec. 9, 2024.

Breast Cancer Screening Begins at Age 40

Routine screening for breast cancer is the best way to detect it early. Breast cancer screening for our members should begin at age 40 rather than age 50, in line with U.S. Preventive Services Task Force recommendations. Learn tips to close screening gaps in our members’ care.

Child and Adolescent Weight Assessment and Nutrition Counseling Can Help Close Care Gaps

The National Committee for Quality Assurance recommends that primary care providers and OB‑GYNs document body mass index percentile and other data for children and adolescents. Talk to your patients about healthy diets and activity levels.

Register for a Coding Webinar on Coagulation Defects and Other Hematological Disorders

Join our Coding Compliance team for a webinar on coding and documentation for coagulation defects. The webinar is free for providers and coding professionals.

Physician Performance Insights Reports Are Now Available

Physician Performance Insights reports are now available for our Physician Efficiency, Appropriateness, & Quality^SM program. PPI reports show how physicians compare to their peers and include information on improving performance.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. Sessions include training on electronic tools and orientation.

Watch for Quality Improvement Program Changes

For contracted providers participating in the Illinois Medicaid Quality Improvement Program, we’re updating how we assess a completion/care gap closure and incentive amounts for the 2025 performance year.

Update Your Information in the IMPACT System

The Centers for Medicare & Medicaid Services requires all Illinois Medicaid providers to revalidate or renew their Medicaid provider information at least every five years. You must complete revalidation to receive payment for services rendered to Illinois Medicaid members. Learn about the revalidation timeline and resources to help.

Mandatory Medicaid Training: Attend a Webinar to Fulfill Annual Requirements

Contracted providers serving members in Blue Cross Community MMAI (Medicare‑Medicaid Plan)^SM or Blue Cross Community Health Plans^SM can fulfill annual training requirements by attending one of our guided webinars.

Prior Authorization Changes

The prior authorization program encourages safe, cost‑effective medication use by allowing coverage when certain conditions are met. Learn about upcoming changes to the standard prior authorization programs effective Nov. 1, 2024. They affect our members who have prescription drug benefits administered by Prime Therapeutics.

Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month under the Standards and Requirements tab. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.