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
Below are links to various care-management-related forms, some of which are used to request authorization for various services. These forms are also available, along with others, on BCN's web-DENIS Forms page. To access the complete Forms Library, log in to Provider Secured Services, click BCN Provider Publications and Resources and then click Forms.
Bariatric surgery
BCN AdvantageSM
Skilled nursing facilities and home health agencies
- Medicare regulations (PDF) (See sections 90.2 through 90.5)
- Notice of Medicare Non-Coverage (DOC)
- Notice of Medicare Non-Coverage (PDF)
- NOMNC form instructions (PDF)
- Detailed Explanation of Non-Coverage (DOC)
- Detailed Explanation of Non-Coverage (PDF)
- DENC form instructions (PDF)
Hospitals, for patients in observation
Hospitals, for inpatients
Noncontracted providers
- Waiver of Liability (PDF)
Member form
- Patient Assessment Form (PDF)
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
Transitional care services
- Home Care Form (PDF) – for BCN Advantage
- LTACH Assessment Form (PDF)
- Enteral and TPN Nutrition Assessment / Follow-up Form (PDF) – for home infusion providers only
- Rehabilitation Assessment Form (PDF)