See Changes to Prior Authorization for Medicare Advantage

Effective Jan. 1, 2026, we’ll review prior authorization requests for certain care categories that previously were reviewed by EviCore healthcare. Learn what’s changing.

See Changes to Coverage for Breast Cancer Screening

We’re updating coverage for certain commercial members to align with federal guidance, effective Jan. 1, 2026.

Enhanced Diagnosis Claim Edits To Follow CMS Guidelines

Effective March 1, 2026, we’ll enhance our claims editing process for many commercial members to help ensure accurate coding and proper reimbursement of services.

Use Proper Coding for Evaluation and Management Services, Modifiers and Oncology Drugs and Services

Effective March 1, 2026, we’ll enhance our claims editing and review process for Medicare and Medicaid claims to monitor the proper use of evaluation and management coding, oncology drugs and services coding, and Modifiers 25 and 59.

Follow‑Up Care Is Recommended for Children Prescribed ADHD Medication

Attention‑deficit/hyperactivity disorder is one of the most common behavioral health disorders affecting children. To support quality care, we gather data on follow‑up visits for children using ADHD medication.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. View the schedule and sign up for sessions.

Review Criteria for Some Osteoarthritis Drugs To Change for Medicaid Members

Medical necessity review criteria for viscosupplementation of osteoarthritis of the knee will change for members with Blue Cross Community Health Plans^SM, effective Jan. 1, 2026.

Signed Form To Be Required for Hospice Authorizations

We’re updating prior authorization requirements for hospice services for members with BCCHP^SM, effective Jan. 1, 2026.

See Updates to Illinois Medicaid Quality Improvement Program Clinical Measures Incentive Program

We’ve updated performance incentive amounts for 2026 for contracted providers participating in the Illinois Medicaid Clinical Measures Incentive Program. View the updates. 

Update Your Records for New Members of Blue Cross Group Medicare Advantage Open Access (PPO)^SM

If you’re a Medicare provider, you may treat these members even if you don’t participate in our Medicare Advantage or other networks.

Provide Medical Records To Support Quality Care

You may receive requests in 2026 for our members’ medical records. We collect data for Healthcare Effectiveness Data and Information Set (HEDIS^®) measures to track quality of care. Learn how you can help by promptly providing complete records for these members:

• Federal Employee Program^®

• Medicaid

• Medicare Advantage

Review Changes to Our Annual National Drug Code Fee Schedule, Impact and Timeline

Reimbursement for services provided on or after Feb. 1, 2026, will be based on the updated fee schedule.

See the Latest Pharmacy Prior Authorization Changes

We’re updating our standard pharmacy prior authorization programs. Changes affect members with prescription drug benefits administered by Prime Therapeutics^®. Review what’s changing as of Feb. 1, 2026.

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.

Review Active and Pending Medical Policies

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.