Authorization Requirements & Criteria

This page provides Blue Cross Blue Shield of Michigan's authorization requirements, including:

As of July 31, 2017, inpatient admission authorization requests for Blue Cross Blue Shield of Michigan commercial PPO and Blue Cross Medicare Plus BlueSM PPO must be submitted through e-referral except for sick newborns and gender reassignment which must be faxed as noted in the table below.

Concurrent review required for Medicare Plus Blue PPO and commercial PPO through URMBT

The application of clinical criteria is required in some cases to receive authorization. Concurrent review will occur for all inpatient admissions for members with Blue Cross Medicare Plus Blue PPO coverage and members with Blue Cross commercial PPO coverage through the UAW Retiree Medical Benefits Trust.

Facilities and providers should request an appropriate number of days when submitting their authorization request based on the member's diagnosis and clinical presentation. Requests for additional days must be submitted through e-referral and must include clinical updates.

If the member is discharged prior to the last covered day, a discharge date should be entered in e-referral. The discharge date and the total number of days the member was inpatient can be added to e-referral as a note. For instructions on how to do this, see the e-referral User Guide (PDF). Go to the Submitting an Inpatient Authorization section, and review the Create New (communication) instructions.

Blue Cross commercial and Blue Cross Medicare Plus Blue PPO inpatient authorization requirements
(See also Services that require authorization - Blue Cross Medicare Plus Blue PPO below.)

    Type of Service Authorization Type Admission date Length of stay – initial request Length of stay – extension request
    Elective surgical inpatient admission Inpatient Enter admission date 3 to 5 days* 5 to 7 days
    Inpatient medical admission** Inpatient Enter admission date 3 to 7 days* 5 to 7 days
    Sick newborns Must be submitted via fax to 1-866-411-2585
    Gender reassignment*** Must be submitted via fax to 1-866-411-2585 until further notice
    Observation Not required for Blue Cross
    Maternity admission Not required for Blue Cross

    *Length of stay request should be appropriate for treatment type.

    **Behavioral health and substance use disorder requests that require an acute inpatient admission must be submitted with a medical diagnosis.

    ***Gender reassignment requests must be submitted with a medical diagnosis.

Services that require authorization – Blue Cross Medicare Plus Blue PPO

Authorization criteria – Blue Cross Medicare Plus Blue PPO


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