e-referral Resources
BCN
Authorizations / Referrals
- Authorization Requirements & Criteria
(formerly Clinical Review & Criteria
Charts) - Provider Manual Chapters
- Autism
- Bariatric Surgery
- Behavioral Health
- eviCore-Managed Procedures
- Forms
- Medical Benefit Drugs – Pharmacy
- MSU Health Plans
- Outpatient PT, OT, ST
- Sleep Management Program
- Spine Care Referral Program
Additional Resources
Authorization Requirements & Criteria
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
- BCN Referral and Authorization Requirements (PDF)
- About Blue Dot Changes to the BCN Referral and Authorization Requirements document (PDF)
- Acute inpatient admission requests: Guidelines for submitting to BCN (PDF)
- Acute inpatient admission requests: Request for Review of Initial Inpatient Admission form (PDF)
- Air ambulance authorization requests for BCN HMOSM (commercial) members:
- 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 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 surgery 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 for adults, 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 for adults, total, revision | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Shoulder replacement surgery procedure, initial | 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) |
- Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
- Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
| Other procedures | |
|---|---|
| Various procedures | Authorization criteria (PDF) |
| Blepharoplasty and repair of brow ptosis | Refer to the medical policy on Blepharoplasty and Repair of Brow Ptosis (PDF) |
| Preview questionnaire (PDF) | |
| Breast biopsy (excisional) | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Cholecystectomy, laparoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Deep brain stimulation | Refer to the medical policy on Deep Brain Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Endometrial ablation (in-office only) | Authorization criteria (medical policy) (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) | |
| Ethmoidectomy, endoscopic | Authorization criteria (PDF) |
| 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) | |
| Noncoronary vascular stents | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Sacral nerve stimulation | Refer to the medical policy on Sacral Nerve Neuromodulation / Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Sinusotomy, frontal endoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement) | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Varicose vein treatment | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Vascular embolization or occlusion (TACE, RFA or UAE) | Refer to the medical policy on:
|
| 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.