
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:
- Log in as a provider at bcbsm.com/providers.
- 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
- Summary of utilization management programs for Michigan providers (PDF)
- Submitting acute inpatient authorization requests: Frequently asked questions for providers (PDF)
- Inpatient authorization requests: Tips for using the e-referral system – Blue Cross PPO (PDF)
- Post-acute care admissions: Submitting authorization requests (PDF)
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
- Northwood DME/POS management program:
- Private duty nursing program (PDF)
- Durable medical equipment and prosthetics and orthotics: For authorization determinations (PDF)
- Diabetes: For coaching, management, behavioral counseling and supplies (PDF) - Includes information about care management and utilization management programs
- Inpatient medical admissions, acute care (hospitals): For authorization determinations (PDF) - Includes information about our utilization management program
- Post-acute care: For skilled nursing, rehabilitation and long-term acute care facilities (PDF) - Includes information about our utilization management programs
- Surgeries: For decision support and authorization determinations (PDF) - Includes information about our care management and utilization management programs
- Transplants: For authorization determinations (PDF) - Includes information about utilization management programs
Utilization management criteria – Blue Cross commercial
- 2022 Blue Cross and BCN Local Rules for acute care (PDF)
- Local Rules for acute care: Frequently asked questions (PDF)
- 2022 Blue Cross and BCN Local Rules for post-acute care (PDF) - for commercial members only
- 2021 Blue Cross modifications of InterQual® criteria, effective Aug. 2, 2021, through July 31, 2022 (PDF)
Forms – Blue Cross commercial
- Criteria Request Form (for non-behavioral health cases) (PDF)
- Acute inpatient hospital 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.
- 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.
- Federal Employee Program® Consent for Case Management (PDF)
- LTACH Assessment Form (PDF) — Michigan and non-Michigan providers should fax the completed form using the fax numbers on the form.
- Peer-to-peer reviews:
- Request for Preauthorization Form (PDF)
Air ambulance authorization requests – Blue Cross commercial
- Air ambulance flight information (non-emergency) form (PDF)
- Air ambulance initiative: Description (PDF)
- Air ambulance: For non-emergency flights (PDF) - Includes information about the utilization management program
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 members
Services that require authorization – Medicare Plus Blue
- 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)
- Submitting acute inpatient authorization requests: Frequently asked questions for providers (PDF)
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
- Cosmetic procedures: For authorization determinations (PDF) - Includes information about our utilization management programs
- Diabetes: For coaching, management, behavioral counseling and supplies (PDF) - Includes information about care management and utilization management programs
- Durable medical equipment and prosthetics and orthotics: For authorization determinations (PDF)
- Elective procedures and services: For authorization determinations (PDF) - Includes information about our care management and utilization management programs
- Inpatient medical admissions, acute care (hospitals): For authorization determinations (PDF) - Includes information about our utilization management program
- Post-acute care:
- Post-acute care services: Frequently asked questions by providers (PDF)
- Post-acute care: For skilled nursing, rehabilitation and long-term acute care facilities (PDF) - Includes information about our utilization management programs
- Surgeries: For decision support and authorization determinations (PDF) - Includes information about our care management and utilization management programs
- 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
Forms – Medicare Plus Blue
- Criteria Request Form (for non-behavioral health cases) (PDF)
- Medicare Plus Blue Acute Inpatient Fax Assessment Form (PDF)
- Peer-to-peer reviews:
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 policies on:
|
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:
|
Preview questionnaire (PDF) |