This page provides Blue Cross Blue Shield of Michigan's authorization requirements, including:
- List of services that require authorization
- Authorization criteria and preview questionnaires for various procedures
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.
Authorization criteria – Blue Cross Medicare Plus Blue PPO
|Surgery, joint replacement and revision|
|Hip replacement surgery procedure, initial||Authorization criteria (PDF)|
|Hip arthroplasty for adults, total, revision||Authorization criteria (PDF)|
|Knee replacement surgery, nonunicondylar||Authorization criteria (PDF)|
|Knee replacement surgery, unicondylar||Authorization criteria (PDF)|
|Knee arthroplasty for adults, total, revision||Authorization criteria (PDF)|
|Shoulder replacement surgery procedure, initial||Authorization criteria (PDF)|
- Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
- Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
|Deep brain stimulation||Refer to the medical policy on Deep Brain Stimulation (PDF)|
|Endovascular intervention, peripheral artery||Authorization criteria (PDF)|
|Enthmoidectomy, endoscopic||Authorization criteria (PDF)|
|Epidural or intrathecal catheter (trial or permanent placement)||Authorization criteria (PDF)|
|Gastric pacing / stimulation||Refer to the medical policy on Gastric Electrical Stimulation (PDF)|
|Hammertoe correction surgery||Authorization criteria (PDF)|
|Noncoronary vascular stents||Authorization criteria (PDF)|
|Sacral nerve stimulation||Refer to the medical policy on Sacral Nerve Neuromodulation/Stimulation (PDF)|
|Sinusotomy, frontal endoscopic||Authorization criteria (PDF)||Spinal cord stimulator (trial or permanent placement)||Authorization criteria (PDF)|
|Vascular embolization or occlusion (TACE, RFA or UAE)||Refer to the medical policy on:
For related information on:
- Care management requirements for various services – refer to the Provider Toolkit page at bcbsm.com. Look under the "Care management" heading.
- Procedures reviewed by eviCore healthcare – refer to the Procedures Managed by eviCore for Blue Cross page in the Blue Cross section of this website.
- Drugs covered under the medical benefit – visit the Medical Benefit Drugs – Pharmacy page in the Blue Cross section of this website.