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- Authorization Requirements & Criteria
(formerly Clinical Review & Criteria
Charts) - Provider Manual Chapters
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Additional Resources
Authorization Requirements & Criteria
Important information during the coronavirus (COVID-19) pandemic
Temporary changes and recommendations for providers:
Find more information for providers:
- Log in as a provider at bcbsm.com/providers.
- Click the special notice at the top of the Provider Secured Services home page.
Below are links to documents detailing Blue Care Network's authorization and referral requirements; 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 Pediatric Choice and Woman's Choice program information.
For drugs covered under the medical benefit, visit the Drugs Covered Under the Medical Benefit 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)
- BCN Referral and Authorization Requirements (PDF)
- About Blue Dot Changes to the BCN Referral and Authorization Requirements document (PDF)
- Procedures codes that require authorization by BCN (PDF)
- Acute inpatient care
- Summary of utilization management programs for Inpatient Acute Hospital Medical Admissions (PDF)
- Acute inpatient admission requests: Guidelines for submitting to BCN (PDF)
- Acute inpatient admission requests: Request for Review of Initial Inpatient Admission form (PDF)
- Post-acute care:
- For BCN HMO members admitted at any time and for BCN Advantage members admitted through May 31, 2019 – Post-acute care admissions: Submitting authorization requests to BCN (PDF)
- For BCN Advantage members admitted on or after June 1, 2019 – Post-acute care services: Frequently asked questions by providers (PDF)
- Air ambulance authorization requests for BCN HMOSM (commercial) members:
- BCN's Local Rules effective Aug. 1, 2019 (PDF)
- BCN Criteria Request Form (for non-behavioral health cases) (PDF)
- Peer-to-peer reviews:
Authorization criteria and preview questionnaires
| Arthroscopy of the knee | |
|---|---|
| All knee arthroscopy procedures | Authorization criteria (PDF) |
| Diagnostic | Preview questionnaire (PDF) |
| Chondroplasty | Preview questionnaire (PDF) |
| Lateral release | Preview questionnaire (PDF) |
| Removal of loose body or foreign body | Preview questionnaire (PDF) |
| Removal or stabilization of intra-articular osteochondral lesion | Preview questionnaire (PDF) |
| Resection or repair of stable or unstable meniscus tear | Preview questionnaire (PDF) |
| Synovectomy, limited | Preview questionnaire (PDF) |
| Synovectomy, major | Preview questionnaire (PDF) |
| Surgery, cervical spine | |
|---|---|
| Cervical spine surgery | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Cervical spine fusion with artificial disc replacement | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Surgery, joint replacement | |
|---|---|
| Hip replacement surgery procedure, initial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Hip arthroplasty, total, revision | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Knee replacement surgery, nonunicondylar, initial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Knee replacement surgery, unicondylar, initial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Knee arthroplasty, total, revision | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Shoulder replacement surgery procedure, initial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Surgery, lumbar spine | |
|---|---|
| Minimally invasive lumbar spine surgery (for BCN Advantage members) | Refer to the medical policy on Spinal Surgery-Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD, MELD, Percutaneous IG-MLD or PILD) for Spinal Stenosis (PDF) |
| Preview questionnaire (PDF) | |
| Other lumbar spine surgery procedures, for dates of service on or after Oct. 3, 2016 | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
- Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
- Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
| Other procedures | |
|---|---|
| Abdominoplasty | Refer to the medical policy on Abdominoplasty (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 HMO (commercial) members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Biofeedback, non-behavioral health | Refer to the medical policy on Biofeedback (PDF) |
| Preview questionnaire for BCN HMO members (PDF) | |
| Preview questionnaire for BCN Advantage members (PDF) | |
| Blepharoplasty and repair of brow ptosis | Refer to the medical policy on Blepharoplasty and Repair of Brow Ptosis (PDF) |
| 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 biopsy (excisional) | Authorization criteria (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 Reduction Mammaplasty 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 HMO (commercial) members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Chemical peels | Refer to the medical policy on Chemical Peels (PDF) |
| Preview questionnaire (PDF) | |
| Cholecystectomy (laparoscopic) | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Cosmetic or reconstructive surgery | Refer to the medical policy on Cosmetic or 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) | |
| Enteral nutrition | Refer to the medical policy on Enteral Nutrition (PDF) |
| Preview questionnaire (PDF) | |
| Epidural or intrathecal catheter (trial or permanent placement) | Authorization criteria (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) | |
| 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 HMO (commercial) | |
| Mastectomy for male gynecomastia | Refer to the medical policy on Mastectomy for male gynecomastia (PDF) |
| Preview questionnaire (PDF) | |
| Noncoronary vascular stents | Authorization criteria (PDF) |
| 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) | |
| Pregnancy termination | Refer to the medical policy on Pregnancy Terminations - Medical and Surgical (PDF) |
| Preview questionnaire (PDF) - for BCN HMO (commercial) members | |
| Preview questionnaire (PDF) - 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, peripheral nerves | Refer to the medical policy on Radiofrequency Ablation of Peripheral Nerves to Treat Pain including Coolief Cooled RF (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) | |
| 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) | |
| Spinal cord stimulator | Authorization criteria (PDF) – for BCN HMO (commercial) members |
| Authorization criteria (PDF) - for BCN Advantage members | |
| Preview questionnaire (PDF) - for BCN HMO (commercial) members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Temporomandibular joint surgery | Refer to the medical policy on Temporomandibular Joint Dysfunction (TMJD) Testing and Treatment (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 policy on:
|
| 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) | |
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.