Access & Training
Blue Cross
Authorizations / Referrals
Additional Resources
Important information during the coronavirus (COVID-19) pandemic
Temporary changes and recommendations for providers:
Find more information for providers:
- Log in as a provider at bcbsm.com/providers.
- Click the special notice at the top of the Provider Secured Services home page.
This page provides Blue Cross Blue Shield of Michigan's authorization requirements, including information that applies to:
For Blue Cross PPO (commercial) members
Information on requesting authorization – Blue Cross PPO (commercial)
- Summary of utilization management programs for Michigan providers (PDF)
- Summary of utilization management programs for Inpatient Acute Hospital Medical Admissions (PDF)
- Inpatient authorization requests: Tips for using the e-referral system – Blue Cross PPO (PDF)
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
Utilization management criteria – Blue Cross PPO (commercial)
Forms – Blue Cross PPO (commercial)
Air ambulance authorization requests – Blue Cross PPO (commercial)
Blue Cross PPO (commercial) Provider Manual
To access the manual, complete these steps:
- Visit bcbsm.com/providers
- Log in to Provider Secured Services.
- Click Provider Manuals.
- Click Blue Cross PPO Provider Manual.
For Medicare Plus Blue PPO members
Services that require authorization – Medicare Plus Blue PPO
- Summary of utilization management programs for Michigan providers (PDF)
- Services That Require Authorization – Medicare Plus Blue PPO (PDF)
- About Blue Dot changes to the list of Services That Require Authorization (PDF)
- Summary of utilization management programs for Inpatient Acute Hospital Medical Admissions (PDF)
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
- For more utilization management requirements for various services refer to the Provider Toolkit page at bcbsm.com. Look under the "Care management" heading. Under the "Care management" heading, click Preauthorization and utilization management.
Utilization management criteria – Medicare Plus Blue PPO
Forms – Medicare Plus Blue PPO
- Medicare Plus Blue PPO Acute Inpatient Fax Assessment Form (PDF)
- Post-acute care:
- For Medicare Plus Blue PPO members admitted through May, 31, 2019 – Non-Michigan Skilled Nursing Facility, Acute Rehabilitation Facility Fax Assessment Form (PDF)
- For Medicare Plus Blue PPO members admitted through May 31, 2019 – LTACH Fax Assessment Form (PDF)
- For Medicare Plus Blue PPO members admitted on or after June 1, 2019 – Post-acute care services: Frequently asked questions by providers (PDF)
- Peer-to-peer reviews:
Authorization criteria and preview questionnaires – Medicare Plus Blue PPO
| Various procedures | |
|---|---|
| Deep brain stimulation | Refer to the medical policy on Deep Brain Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Endovascular intervention, peripheral artery | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Epidural or intrathecal catheter (trial or permanent placement) | 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) | |
| Noncoronary vascular stents | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Sacral nerve neuromodulation/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 | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Vascular embolization or occlusion of hepatic tumors (TACE/RFA) | Refer to the medical policy on:
|
| Preview questionnaire (PDF) | |
The following documents pertain to procedures for which the Medicare Plus Blue Utilization Management department manages authorizations for dates of service prior to July 1, 2020.
For dates of service on or after July 1, 2020, TurningPoint Healthcare Solutions, LLC manages authorization requests. You can submit authorization requests to TurningPoint starting on June 1, 2020. See the Musculoskeletal Services page for more information.
| Certain Musculoskeletal procedures, for dates of service before June 1, 2020 |
|
|---|---|
| Hip replacement surgery procedure, initial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Hip arthroplasty, 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, total, revision | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Shoulder replacement surgery procedure, initial | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
For related information on:
- Procedures reviewed by eviCore healthcare – refer to the Procedures Managed by eviCore for Blue Cross page in the Blue Cross section of this website.
- Joint and spinal procedures that require authorization by TurningPoint - see the Musculoskeletal Services page in the Blue Cross section of this website.
- Drugs covered under the medical benefit – visit the Medical Benefit Drugs – Pharmacy page in the Blue Cross section of this website.