Access & Training
BCN
Authorizations / Referrals
- Authorization Requirements & Criteria
- Provider Manual Chapters
- AIM-Managed Procedures
- Autism
- Bariatric Surgery
- Behavioral Health
- Blue Elect Plus POS
- eviCore-Managed Procedures
- Forms
- Home Health Care
- Medical Benefit Drugs
- MSU Health Plans
- Musculoskeletal Services
- Outpatient PT, OT, ST
- Pharmacy Benefit Drugs
- Sleep Management Program
Additional Resources
Authorization Requirements & Criteria
Important information during the coronavirus (COVID-19) pandemic
For temporary changes and recommendations for providers, refer to our COVID-19 provider webpage.
Find more information for providers:
- Log in as a provider at bcbsm.com/providers.
- Click Coronavirus (COVID-19).
Below are links to documents detailing Blue Care Network's authorization and referral requirements for services managed by BCN, including lists of procedures that require authorization and authorization criteria and preview questionnaires for various procedures. These apply to services other than drugs covered under the medical benefit. In addition, there are links to information about the Pediatric Choice and Woman's Choice programs.
For drugs covered under the medical benefit, visit the Medical Benefit Drugs page in the BCN section of this website.
For Blue Cross Complete utilization management information, go to MiBlueCrossComplete.com/providers.
Referral and authorization information
- Summary of utilization management programs for Michigan providers (PDF)
- Authorization requirements documents
- BCN referral and authorization requirements for Michigan providers (PDF)
- About Blue Dot Changes to the BCN referral and authorization requirements document for Michigan providers (PDF)
- BCN-managed procedure codes that require authorization for Michigan providers (PDF)
- Non-Michigan providers: Referral and authorization requirements for BCN members (PDF)
- Acute inpatient care
- Submitting acute inpatient authorization requests: Frequently asked questions for providers (PDF)
- Acute inpatient admission requests: Request for Review of Initial Inpatient Admission form (PDF)
- Guidelines for bundling admissions (PDF)
- Inpatient medical admissions, acute care (hospitals): For authorization determinations (PDF) - Includes information about our utilization management program
- Post-acute care:
- For BCN commercial members – Post-acute care admissions: Submitting authorization requests to BCN (PDF)
- For BCN Advantage members – Post-acute care services: Frequently asked questions by providers (PDF)
- Post-acute care: For skilled nursing, rehabilitation and long-term acute care facilities (PDF) - Includes information about our utilization management programs
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
- Air ambulance authorization requests for BCN commercial members:
- Air ambulance flight information (non-emergency) form (PDF)
- Air ambulance initiative: Description (PDF)
- Air ambulance: For non-emergency flights (PDF) - Includes information about the utilization management program
- BCN's Local Rules:
- 2022 Blue Cross and BCN Local Rules for acute care (PDF)
- Local Rules for acute care: Frequently asked questions (PDF)
- 2022 Blue Cross and BCN Local Rules for post-acute care (PDF) - for commercial members only
- BCN's Local Rules effective Aug. 2, 2021, through July 31, 2022 (PDF)
- Criteria Request Form (for non-behavioral health cases) (PDF)
- Peer-to-peer reviews:
- Cardiology: For home monitoring and cardiology and echocardiology procedures (PDF)- Includes information about care management and utilization management programs
- Chiropractic services: For chiropractic manipulations and physical medicine services by chiropractors (PDF) — Includes information about utilization management programs
- Cosmetic procedures: For authorization determinations (PDF) — Includes information about our utilization management programs
- Diabetes: For coaching, management, behavioral counseling and supplies (PDF) — Includes information about care management and utilization management programs
- Durable medical equipment and prosthetics and orthotics: For authorization determinations (PDF) — Includes information about care management and utilization management programs
- Elective procedures and services: For authorization determinations (PDF) — Includes information about care management and utilization management programs
- Laboratory: For genetic testing and molecular testing (PDF) — Includes information about our utilization management programs
- Outpatient medical rehabilitation: For authorization determinations (PDF) — Includes information about our utilization management programs
- Surgeries: For decision support and authorization determinations (PDF) — Includes information about our care management and utilization management programs
- Transplants: For authorization determinations (PDF) — Includes information about utilization management programs
Authorization criteria and preview questionnaires
- Blepharoplasty and Repair of Brow Ptosis (PDF)
- Cosmetic and Reconstructive Surgery (PDF)
- Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
- Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
| Various procedures | |
|---|---|
| Abdominoplasty | Refer to the medical policy on Abdominoplasty (PDF) |
| Preview questionnaire (PDF) | |
| Ambulatory event monitors, implantable | Refer to the medical policy on Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry (PDF) |
| Preview questionnaire (PDF) | |
| Artificial heart, total | Refer to the medical policy on Total Artificial Hearts and Implantable Ventricular Assist Devices (PDF) |
| Preview questionnaire (PDF) | |
| Bariatric surgery | Refer to the medical policy on Bariatric Surgery (Gastric Surgery for Morbid Obesity) (PDF) |
| Preview questionnaire (PDF) - for BCN commercial members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Biofeedback, non-behavioral health | Refer to the medical policy on Biofeedback (PDF) |
| Preview questionnaire (PDF) - for BCN commercial members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Blepharoplasty and repair of brow ptosis | Refer to the medical policy on Blepharoplasty and Repair of Brow Ptosis (PDF) |
| Preview questionnaire (PDF) | |
| Blepharoplasty, lower lid repair | Refer to the medical policies on:
|
| Preview questionnaire (PDF) | |
| Bone-anchored hearing aid | Refer to the medical policy on Implantable Bone-Conduction and Bone-Anchored Hearing Devices (PDF) |
| Preview questionnaire (PDF) | |
| Breast implant management | Refer to the medical policy on Reconstructive Breast Surgery / Management of Breast Implants (PDF) |
| Preview questionnaire (PDF) | |
| Breast reconstruction | Refer to the medical policy on Reconstructive Breast Surgery / Management of Breast Implants (PDF) |
| Preview questionnaire (PDF) | |
| Breast reduction | Refer to the medical policy on Breast Reduction for Breast-Related Symptoms (PDF) |
| Preview questionnaire (PDF) | |
| Cardiac rehabilitation | Refer to the medical policy on Cardiac Rehabilitation, Outpatient (PDF) |
| Preview questionnaire (PDF) - for BCN commercial members | |
| Chemical peels, dermal | Refer to the medical policy on Chemical Peels (PDF) |
| Preview questionnaire (PDF) | |
| Chemical peels, epidermal | Refer to the medical policy on Chemical Peels (PDF) |
| Preview questionnaire (PDF) | |
| Cholecystectomy (laparoscopic) | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Cognitive rehabilitation | Refer to the medical policy on Cognitive Rehabilitation (PDF) |
| Preview questionnaire (PDF) | |
| Cosmetic or reconstructive surgery | Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Deep brain stimulation | Refer to the medical policy on Deep Brain Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Dental anesthesia or immediate repair of trauma to natural teeth | Refer to the medical policy on Dental Anesthesia (PDF) |
| Refer to the medical policy on Immediate Repair of Trauma to Natural Teeth (PDF) | |
| Preview questionnaire (PDF) | |
| Endoscopy, upper gastrointestinal, for gastroesophageal reflux disease | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Endovascular intervention, peripheral artery | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Endovenous ablation for treatment of varicose veins | Refer to the medical policy on Endovenous Ablation for the Treatment of Varicose Veins (PDF) |
| Preview questionnaire (PDF) | |
| Enteral nutrition | Refer to the medical policy on Enteral Nutrition (PDF) |
| Preview questionnaire (PDF) | |
| Ethmoidectomy, endoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Excess skin removal | Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Experimental and investigational services | Preview questionnaire (PDF) |
| Facial and neck hair removal (for University of Michigan employees only) | Preview questionnaire (PDF) |
| Facial feminization surgery and chondrolaryngoplasty (for University of Michigan employees only) | Preview questionnaire (PDF) |
| Gastric pacing / stimulation | Refer to the medical policy on Gastric Electrical Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Hammertoe correction surgery | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Hyperbaric oxygen therapy | Refer to the medical policy on Hyperbaric Oxygen Therapy – Systemic and Topical (PDF) |
| Preview questionnaire (PDF) for BCN Advantage | |
| Preview questionnaire (PDF) for BCN commercial | |
| Hypoglossal nerve stimulator — condition trigger | Preview questionnaire (PDF) |
| Hypoglossal nerve stimulator — adolescent or young adult | Refer to the medical policy on Obstructive Sleep Apnea and Snoring - Surgical Treatment (PDF) |
| Preview questionnaire (PDF) | |
| Hypoglossal nerve stimulator — adolescents with Down syndrome | Refer to the medical policy on Obstructive Sleep Apnea and Snoring - Surgical Treatment (PDF) |
| Preview questionnaire (PDF) | |
| Hypoglossal nerve stimulator — adults | Refer to the medical policy on Obstructive Sleep Apnea and Snoring - Surgical Treatment (PDF) |
| Preview questionnaire (PDF) | |
| Left atrial appendage closure | Refer to the medical policy on Percutaneous Left Atrial Appendance Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF) |
| Preview questionnaire (PDF) - for BCN commercial members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Medical formula for inborn errors of metabolism | Refer to the medical policy on Medical Formula for Inborn Errors of Metabolism (PDF) |
| Preview questionnaire (PDF) | |
| Noncoronary vascular stents | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Not otherwise classified codes | Preview questionnaire (PDF) |
| Oral surgery | Refer to the medical policy on Oral Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Orthognathic surgery | Refer to the medical policy on Orthognathic Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Otoplasty | Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Pediatric feeding program | Refer to the medical policy on Pediatric Feeding Programs (PDF) |
| Preview questionnaire (PDF) | |
| Pregnancy termination | Refer to the medical policy on Pregnancy Terminations - Medical and Surgical (PDF) |
| Preview questionnaire (PDF) - for medically necessary pregnancy terminations for BCN commercial members | |
| Preview questionnaire (PDF) - for elective pregnancy terminations for BCN commercial members | |
| Preview questionnaire (PDF) - for medically necessary or elective pregnancy terminations for BCN Advantage members | |
| Prostatic urethral lift | Refer to the medical policy on Prostatic Urethral Lift Procedure for the Treatment of BPH (PDF) |
| Preview questionnaire (PDF) | |
| Pulmonary rehabilitation | Refer to the medical policy on Pulmonary Rehabilitation (PDF) |
| Preview questionnaire (PDF) | Radiofrequency ablation (RFA), cardiac, trigger | Refer to the medical policy on Preview questionnaire (PDF) |
| Radiofrequency ablation (RFA), cardiac atrial fibrillation or atrial flutter | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Radiofrequency ablation (RFA), cardiac frequent monomorphic premature ventricular contractions | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Radiofrequency ablation (RFA), cardiac nonsustained ventricular tachycardia | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Radiofrequency ablation (RFA), cardiac suspected AVNRT, AVRT or focal atrial tachycardia | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Radiofrequency ablation (RFA), cardiac sustained (more than 30 seconds) ventricular tachycardia | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Radiofrequency ablation (RFA), cardiac treatment for preexcitation syndrome or WPW syndrome | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Rhinoplasty | Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Sacral nerve neuromodulation/stimulation | Refer to the medical policy on Sacral Nerve Neuromodulation / Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Septoplasty | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Sinusotomy, frontal, endoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Sleep studies, outpatient facility and clinic-based | Refer to the medical policy on Sleep Disorders, Diagnosis and Medical Management (PDF) |
| Preview questionnaire (PDF) | |
| Surgical treatment for male gynecomastia | Refer to the medical policy on Surgical treatment for male gynecomastia (PDF) |
| Preview questionnaire (PDF) | |
| Temporomandibular joint surgery | Refer to the medical policy on Temporomandibular Joint Dysfunction (TMJD) Testing and Treatment (PDF) |
| Preview questionnaire (PDF) | |
| Thyroidectomy, partial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Thyroidectomy, total | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Varicose vein treatment | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Vascular embolization or occlusion of hepatic tumors (TACE/RFA) | Refer to the medical policies on:
|
| Preview questionnaire (PDF) | |
| Ventricular assist devices | Refer to the medical policy on Total Artificial Hearts and Implantable Ventricular Assist Devices (PDF) |
| Preview questionnaire (PDF) | |
| Visual training, orthoptic and pleoptic | Refer to the medical policy on Orthoptic Training/Vision Therapy for the Treatment of Vision or Learning Disabilities (PDF) |
| Preview questionnaire (PDF) | |
| Out-of-network providers — For prior authorization requests for procedures to be completed by providers who aren’t contracted with BCN | Preview questionnaire (PDF) |
Pediatric Choice
Woman's Choice
The Woman's Choice program allows BCN members to directly access affiliated physicians who perform obstetric or gynecologic services. In line with Woman's Choice guidelines, an obstetrician-gynecologist may perform or order some services without a referral from the primary care physician.