Utilization Management Forms

Below are links to various utilization-management-related forms, some of which are used to request authorization for various services. These forms are also available, along with others, on our Provider Resources site. To access the forms:

  1. Log in to our provider portal (availity.com*).
  2. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
  3. Click the Resources tab.
  4. Click Secure Provider Resources (Blue Cross and BCN).
  5. Click the Forms menu and make the appropriate selection.

BCN AdvantageSM

Skilled nursing facilities and home health agencies

Hospitals, for patients in observation

Hospitals, for inpatients

Noncontracted providers

Member form

Behavioral health services

Drugs covered under the medical benefit

For information about drugs covered under the medical benefit, visit the Medical Benefit Drugs – Pharmacy page on this website.

e-referral

Sign up or change a user

Transitional care services

  • LTACH assessment form (PDF) — Michigan and non-Michigan providers should fax the completed form using the fax numbers on the form.
  • SNF/acute IPR assessment form (PDF) — Michigan providers should attach the completed form to the request in the e-referral system. Non-Michigan providers should fax the completed form using the fax numbers on the form.

Note: For BCN Advantage members admitted to post-acute care, see Post-acute care services: Frequently asked questions by providers (PDF).


*Clicking this link means that you’re leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we’re not responsible for its content.