Clinical Review & Criteria Charts

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

Referral / clinical review information

Authorization criteria and preview questionnaires

Pain management services

For dates of service on or after Sept. 1, 2016:

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.