When a patient needs behavioral health care, Blue Cross Blue Shield of Michigan may need to approve it first. Keep in mind that authorization is just a clinical review approval, not a guarantee of payment. You'll still need to verify the necessary coverage for this medical benefit.
For both Blue Cross PPO and Medicare Plus BlueSM PPO members
The documents linked here apply to both Blue Cross PPO and Medicare Plus Blue PPO members.
- Telemedicine (PDF) medical policy.
- Outpatient detoxification and follow-up care protocols for treating substance use disorders (PDF)
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
- Behavioral health: For mental health and substance use disorders (PDF) - Includes information about care management and utilization management programs
For behavioral health medical record documentation requirements for outpatient services:
- Documentation requirements for applied behavior analysis services (PDF)
- Documentation requirements and privacy regulations for services other than ABA (PDF)
See below for additional resources that apply either to Blue Cross PPO or to Medicare Plus Blue PPO members.
For Blue Cross PPO (commercial) members
Most, but not all, Blue Cross PPO members have their behavioral health coverage managed by New Directions.
To determine whether a group or member's benefits are managed by New Directions or by another organization, contact a behavioral health care manager using the toll-free number on the back of the member's ID card. You can also refer to the Blue Pages Directory chapter of the Blue Cross PPO provider manual for complete contact information.
Here's where to find additional information:
- For authorizations by New Directions, you can use the New Directions WebPass tool* to request initial and concurrent reviews for inpatient, residential, partial hospital, applied behavior analysis and transcranial magnetic stimulation services and to check the status of these requests. You can also call 1-800-762-2382.
- For additional information about behavioral health services, refer to the Blue Cross PPO provider manuals. To access this and other resources, log in to Provider Secured Services and click web-DENIS.
- LLPs and LMFTs — Frequently asked questions (PDF)
- Requirements for providing behavioral health services to Blue Cross PPO (commercial) members (PDF)
For Medicare Plus Blue PPO members
Effective Oct. 16, 2017, the following behavioral health services for Medicare Plus Blue PPO members require authorization through the e-referral system:
- Initial admission of inpatient, partial hospital and intensive outpatient treatment for members who have been admitted to inpatient care or to a treatment program
- Extensions of inpatient, partial hospital, intensive outpatient treatment
Outpatient behavioral health services for Medicare Plus Blue PPO members do not require authorization.
Here are some resources to assist you in managing behavioral health services:
- Assistance in using the e-referral system
- Behavioral Health e-referral User Guide (PDF)
- Submitting authorization requests: Frequently asked questions for behavior health providers, for Medicare Plus Blue PPO (PDF)
- Behavioral Health Discharge Summary (PDF) - Attach this to the case in the e-referral system.
- Utilization management criteria
- InterQual® — Medicare Plus Blue PPO uses Change Healthcare's InterQual Behavioral Health Criteria as utilization management guidelines subject to the modifications posted below. To request a copy of the specific InterQual criteria used to make a decision on a member's case, call Medicare Plus Blue PPO Behavioral Health at 1-888-803-4960.
- Modifications of InterQual criteria starting Aug. 1, 2020 — Medicare Plus Blue PPO uses these modifications of InterQual criteria for decisions about substance use disorders (partial hospital program and intensive outpatient program) (PDF) and mental health disorders (partial hospital program and intensive outpatient program) (PDF).
- Modifications of InterQual criteria from Aug. 1, 2019, through July 31, 2020 — Medicare Plus Blue PPO uses these modifications of InterQual criteria for decisions about substance use disorders (partial hospital program and intensive outpatient program) (PDF).
- Modifications of InterQual criteria from Aug. 6, 2018, through July 31, 2019 — Medicare Plus Blue PPO uses these modifications of InterQual criteria for decisions about substance use disorders (partial hospital program and intensive outpatient program) (PDF).
- Medicare Plus Blue Provider Manual (PDF) — In the "Utilization management" section, look for the subsection titled "Preauthorization of behavioral health services."
You can call Medicare Plus Blue PPO Behavioral Health at 1-888-803-4960 for general assistance with behavioral health services, including:
- Arranging services or requesting authorization for services
- Obtaining criteria used to make an authorization decision
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