Authorization Requirements & Criteria

Important information during the coronavirus (COVID-19) pandemic

For temporary changes and recommendations for providers, refer to our COVID-19 provider webpage

Find more information for providers:

  1. Log in as a provider at bcbsm.com/providers.
  2. Click Coronavirus (COVID-19).

This page provides Blue Cross Blue Shield of Michigan's authorization requirements, including information that applies to:

For Blue Cross commercial members

Information on requesting authorization – Blue Cross commercial

Utilization management criteria – Blue Cross commercial

Forms – Blue Cross commercial

Air ambulance authorization requests – Blue Cross commercial

Blue Cross PPO (commercial) Provider Manual

To access the manual, complete these steps:

  1. Visit bcbsm.com/providers
  2. Log in to Provider Secured Services.
  3. Click Provider Manuals.
  4. Click Blue Cross PPO Provider Manual.

For Medicare Plus Blue members

Services that require authorization – Medicare Plus Blue

Utilization management criteria – Medicare Plus Blue

Forms – Medicare Plus Blue

Authorization criteria and preview questionnaires – Medicare Plus Blue

Various procedures
Ambulatory event monitors, implantable Refer to the medical policy on Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry (PDF)
Preview questionnaire (PDF)
Blepharoplasty and repair of brow ptosis Refer to the medical policy on Blepharoplasty and Repair of Brow Ptosis (PDF)
Preview questionnaire (PDF)
Blepharoplasty, lower lid repair Refer to the medical policy on Blepharoplasty and Repair of Brow Ptosis (PDF)
Preview questionnaire (PDF)
Cosmetic and Reconstructive Surgery Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF)
Preview questionnaire (PDF)
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)
Endovenous ablation for treatment of varicose veins Refer to the medical policy on Endovenous Ablation for the Treatment of Varicose Veins (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)
Left atrial appendage closure Refer to the medical policy on Percutaneous Left Atrial Appendance Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF)
Preview questionnaire (PDF)
Noncoronary vascular stents Authorization criteria (PDF)
Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac, trigger Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac atrial fibrillation or atrial flutter Authorization criteria (PDF)
Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac frequent monomorphic premature ventricular contractions Authorization criteria (PDF)
Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac nonsustained ventricular tachycardia Authorization criteria (PDF)
Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac suspected AVNRT, AVRT or focal atrial tachycardia Authorization criteria (PDF)
Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac sustained (more than 30 seconds) ventricular tachycardia Authorization criteria (PDF)
Preview questionnaire (PDF)
Radiofrequency ablation (RFA), cardiac treatment for preexcitation syndrome or WPW syndrome Authorization criteria (PDF)
Preview questionnaire (PDF)
Rhinoplasty Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF)
Preview questionnaire (PDF)
Sacral nerve neuromodulation/stimulation Refer to the medical policy on Sacral Nerve Neuromodulation / Stimulation (PDF)
Preview questionnaire (PDF)
Septoplasty Authorization criteria (PDF)
Preview questionnaire (PDF)
Sinusotomy, frontal, endoscopic Authorization criteria (PDF)
Preview questionnaire (PDF)
Thyroidectomy, partial Authorization criteria (PDF)
Preview questionnaire (PDF)
Thyroidectomy, total Authorization criteria (PDF)
Preview questionnaire (PDF)
Vascular embolization or occlusion of hepatic tumors (TACE/RFA) Refer to the medical policies on:
  • Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
  • Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
  • Preview questionnaire (PDF)