Access & Training
Blue Cross
Referrals & Authorizations
- Prior Authorization
- Acute Inpatient Admissions
- Air Ambulance
- Autism
- Behavioral Health
- Cardiology
- Diabetes Supplies
- DME / P&O
- Home Health Care
- Medical Benefit Drugs
- Musculoskeletal Services
- Oncology
- Pain Management Services
- Pharmacy Benefit Drugs
- Post-Acute Care
- Private Duty Nursing
- Radiology
- Sleep Studies
- Transplant Services
Blue Cross Products with
Unique Requirements
Additional Resources
Oncology Services
Blue Cross Blue Shield of Michigan requires prior authorization for oncology services as follows.
| Service | Members | Managed by |
|---|---|---|
| Medical Oncology | See the following webpages on this website: | |
| Proton beam therapy |
|
EviCore by Evernorth® |
Blue Cross commercial self-funded groups:
|
Carelon Medical Benefits Management | |
| Radiation oncology, other than proton beam therapy |
|
EviCore |
| Blue Cross commercial self-funded groups — For UAW Retiree Medical Benefits Trust non-Medicare members only | Carelon | |
Notes:
- For Blue Cross commercial groups, see the Carelon exclusion list for Blue Cross Blue Shield of Michigan Commercial (PDF) to learn about the health plans, groups, and settings or scenarios for which prior authorization isn't required.
- The requirements outlined above don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).
- For information about oncology services for oncology services for Blue Care Network commercial and BCN AdvantageSM members, see the BCN Oncology Services page.
How to submit prior authorization requests
To learn how to submit requests, see our Getting Started page.
Submit requests before providing services.
Utilization management criteria
- To view utilization management criteria for commercial members, go to the Services That Need Prior Authorization page on bcbsm.com.
- To view utilization management criteria for Medicare Advantage members, go to the Medicare Advantage Prior Authorization page on bcbsm.com.
Resources for services managed by Carelon
- For most members: Procedures that require prior authorization by Carelon: Cardiology, radiation oncology, radiology (high technology) and sleep studies (in lab) (PDF)
- For URMBT non-Medicare members: Radiation Oncology Prior Authorization List for UAW Retiree Medical Benefits Trust non-Medicare members (PDF) — A list of radiation oncology procedures that require prior authorization for URMBT non-Medicare members. Includes modalities, grouper ID required codes and grouper names
- Frequently asked questions about Carelon: For cardiology, radiology (high technology) and sleep studies (in lab) (PDF) — Answers to questions about prior authorization requirements for cardiology services, high-tech radiology services and in-lab sleep studies
- Carelon's Clinical guidelines and pathways*
Resources for services managed by EviCore
- Procedure codes for which providers must request prior authorization (PDF) — See this document to determine which procedure codes require prior authorization
- Services reviewed by eviCore for Blue Cross and BCN (PDF) — Outlines the types of services for which eviCore manages prior authorizations, how to submit requests, where to find clinical criteria and guidelines, and more
- Authorizations Quick Reference Guide (PDF) — Explains how to submit prior authorization requests to eviCore
Additional resources
- Oncology: For CAR-T cell therapy, medical oncology and radiation oncology (PDF) — Includes information about utilization management programs
*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.
Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.
EviCore by Evernorth is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.