See Our BlueCard^® Program Checklist for Out‑of‑Area Member Claims

As part of our BlueCard program, you may see members with Blue Cross and Blue Shield Plans from other states. Review our checklist for filing out‑of‑area member claims.

Update: Waiver Review for Out‑of‑State Care Beyond Contiguous Counties

Waivers granted to members receiving out‑of‑state care beyond the border counties of Wisconsin, Iowa, Missouri, Kentucky and Indiana will be subject to periodic review.

Take Note of Prior Authorization Changes for Commercial and Government Plans

Effective Oct. 1, 2025, prior authorization requirements for certain commercial and government plans are changing to reflect new, replaced or removed codes.

Encourage Pediatric Well‑Child Visits and Immunizations

We track quality measures to help close gaps in our members’ care. See tips for documenting visits and vaccines.

Review New Clinical Practice Guideline on Hepatitis C

We adopted a guideline on testing, managing and treating hepatitis C virus from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America. Learn about the recommendations.

See Resource on ICD‑10 Z Codes to Help Track Members’ Social Needs

We encourage adding ICD‑10‑CM Z codes on claims to document social determinants of health that may affect our members. Refer to our flyer for sample codes.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. View the schedule and sign up for sessions, including training on behavioral health quality measures for Medicaid providers.

Medicaid Providers: Update Your Information in the IMPACT System

The Illinois Department of Healthcare and Family Services notified us of an increase in Medicaid providers being terminated for not revalidating or renewing their information through the Illinois Medicaid Program Advanced Cloud Technology system. You must complete revalidation to receive payment for services rendered to Illinois Medicaid members.

Review Claims Processing Changes for Blue Cross Community Health Plans^SM

Effective Aug. 1, 2025, we changed how we process claims for members with BCCHP^SM. These changes don’t apply to claims for Blue Cross Community MMAI (Medicare‑Medicaid Plan)^SM.

Transition to Carelon for Medicaid Prior Authorization Requests

We’ve changed the vendor for prior authorizations for members with BCCHP. As of Aug. 1, 2025, Carelon Medical Benefits Management will review some requests previously reviewed by EviCore healthcare. View reminders on how to submit requests to Carelon and where to go for on‑demand training.

Encourage Members to Use Virtual Visits for Urgent Care After Hours

If our members with BCCHP need to receive care after hours or while traveling, they may access MDLIVE^® Virtual Visits for urgent, non‑emergency medical conditions. Consider telling our members about this benefit if they need services when your office isn’t available.

Provide Records to Support Risk Adjustment Data Validation Audit

You may receive medical record requests for the Centers for Medicare & Medicaid Services’ RADV audit. If you receive a letter from us and our vendor, please respond as soon as possible.

Verify Your Directory Information Every 90 Days

Our members rely on our provider directory for accurate information about your practice. Directory information for commercial providers must be verified every 90 days. We require commercial provider groups and encourage commercial solo providers to submit a complete roster every 90 days to meet verification requirements.

Review Reminder on Billing Point‑of‑Use Convenience Kits

These prepackaged kits include supply items in addition to injectable medicine. We reimburse only the drug component of the kits.

Pharmacy Program Quarterly Update — Part 2

Changes were made to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

See the Latest Pharmacy Prior Authorization Changes

We’re making updates to our standard pharmacy prior authorization programs. Changes affect members with prescription drug benefits administered by Prime Therapeutics. Review what’s changing on Sept. 1 and Sept. 15, 2025.

Learn About Updates to Clinical Payment and Coding Policies

We regularly add and modify CPCPs as part of our ongoing policy review. See which policies were updated and when.

Review 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. 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.