e-referral Resources
BCN
Authorizations / Referrals
Additional Resources
Below are links to documents detailing Blue Care Network's regional clinical review requirements; lists of procedures that require clinical review; 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 on this website.
For Blue Cross Complete utilization management information, go to MiBlueCrossComplete.com/providers.
Referral / clinical review information
- Blue Care Network Referral and Clinical Review Program (PDF)
- About Blue Dot Changes to the Referral and Clinical Review Program (PDF)
- Acute inpatient admission requests: Guidelines for submitting to BCN (PDF)
- Acute inpatient admission requests: Request for Review of Initial Inpatient Admission form (PDF)
- BCN's current Local Rules (PDF)
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 or stabilization of intra-articular osteochondral lesion or loose body | Preview questionnaire (PDF) |
| Resection or repair of stable or unstablce 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 surgery with artificial disc replacement | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Surgery, joint replacement | |
|---|---|
| Hip replacement surgery procedures | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Knee replacement surgery, nonunicondylar | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Knee replacement surgery, unicondylar | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Shoulder replacement surgery procedures | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Surgery, lumbar spine | |
|---|---|
| All lumbar spine surgery procedures, for dates of service on or after Oct. 3, 2016 | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Discectomy/hemilaminectomy, for dates of service prior to Oct. 3, 2016 | Preview questionnaire (PDF) |
| Lumbar fusion, for dates of service prior to Oct. 3, 2016 | Preview questionnaire (PDF) |
| Lumbar laminectomy, for dates of service prior to Oct. 3, 2016 | Preview questionnaire (PDF) |
| Other procedures | |
|---|---|
| Various procedures | Authorization criteria (PDF) |
| Anesthesia (monitored anesthesia care) used with GI endoscopy procedures | Authorization criteria (medical policy) (PDF) |
| Frequently asked questions (PDF) | |
| Breast biopsy (excisional) | Preview questionnaire (PDF) |
| Cholecystectomy, laparoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Contrast-enhanced coronary CT angiography | Preview questionnaire (PDF) |
| Endometrial ablation (in-office only) | Preview questionnaire (PDF) |
| Varicose vein treatment | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Zoledronic acid | Preview questionnaire (PDF) |
Pain management services
For dates of service on or after Sept. 1, 2016:
- Visit the eviCore-Managed Procedures page on this website.
For dates of service prior to Sept. 1, 2016, refer to the resources below:
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.