e-referral Resources
BCN
Authorizations / Referrals
- Authorization Requirements & Criteria
(formerly Clinical Review & Criteria
Charts) - Provider Manual Chapters
- AIM-Managed Procedures
- 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 utilization-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 Forms page within Provider Secured Services. 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 (for members admitted through May 31, 2019) 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) – for BCN HMO members admitted anytime and for BCN Advantage members admitted through May 31, 2019
- Enteral and TPN Nutrition Assessment / Follow-up Form (PDF) – for home infusion providers only
- Rehabilitation Assessment Form (PDF) – for BCN HMO members admitted anytime and for BCN Advantage members admitted through May 31, 2019
Note: For BCN Advantage members admitted to post-acute care on or after June 1, 2019, see Post-acute care services: Frequently asked questions by providers (PDF).