Blue Cross Behavioral Health^SM manages prior authorizations for autism treatment for the following members:

• Blue Care Network commercial
• BCN Advantage^SM

Notes:

• Autism benefits for BCN commercial members comply with Michigan-mandated benefits. The mandate doesn’t apply to some self-funded employer groups or to Medicare Advantage or Medicare supplement plans, such as BCN Advantage^SM or MyBlue Medigap^SM. Always check member benefits and eligibility.
• For information about autism services for Blue Cross Blue Shield of Michigan and Medicare Plus Blue^SM members, see the Blue Cross Autism Services page.

How to submit prior authorization requests

To learn how to submit requests, see our Getting Started page. Submit requests before providing services.

To find out more about the 2024 changes, view the Blue Cross Behavioral Health Updates 2024 Webinar (video).

Out-of-network providers can use the online forms below to submit requests. For best results, use the Google Chrome^™ browser to open and complete these forms.

• Applied Behavioral Analysis Assessment Form*
• Applied Behavior Analysis Treatment Request Form*

Utilization management criteria

• To view utilization management criteria, go to the Services That Need Prior Authorization page on bcbsm.com.
• To view Blue Cross and BCN’s medical policies, go to the Medical Policy Router Search webpage on bcbsm.com.

Autism resources

• Blue Cross Behavioral Health: Frequently asked questions for providers (PDF)
• Autism coverage overview (PDF)
• Obtaining an autism diagnostic evaluation and finding treatment (PDF)
• Documentation requirements for autism services (PDF)
• Autism diagnostic evaluation results form (PDF)
• Requirements for diagnostic evaluations by approved autism evaluation centers and independent evaluation teams (PDF)
• Letter of intent to become an approved autism evaluation center (PDF)
• AAEC evaluation and billing guidelines (PDF)
• Attestation form for psychologists interested in providing ABA (PDF)
• Autism: Billing guidelines and procedure codes (PDF)
• Behavioral health: For mental health and substance use disorders (PDF) — Includes information about care management and utilization management programs

Telehealth resources

• Telemedicine medical policy — To view this document, go to the Medical Policy Router Search webpage on bcbsm.com, enter the name of the medical policy in the Policy/Topic Keyword field and press Enter.
• Telehealth for behavioral health providers (PDF)
• Guidelines for autism interventions delivered via telemedicine (ABA and skills training) (PDF)

Autism-related physical, occupational and speech therapy services and physical medicine services by athletic trainers and chiropractors

Prior authorization requirements vary as follows:

• For dates of service on or after Jan. 1, 2024, prior authorization isn’t required for any member for autism-related PT, OT or ST by therapists or physical medicine services by athletic trainers or chiropractors.
• For dates of service before Jan. 1, 2024, autism-related PT, OT and ST by therapists and physical medicine services by athletic trainers and chiropractors are managed as follows:
• For members 19 years of age or older, EviCore by Evernorth^® manages prior authorization requests. Submit requests to EviCore. See our Getting Started page for details.
• For members under age 19, prior authorization isn’t required. Claims for these services pay without a referral or an authorization when they’re billed by a BCN-contracted provider and with a childhood autism diagnosis code (F84.0, F84.5, F84.8 or F84.9).

A physician must write an order or prescription for therapy.

Autism-related PT, OT and ST by therapists and physical medicine services by athletic trainers and chiropractors are subject to medical outpatient therapy deductibles, copayments or coinsurance. For other outpatient autism-related services, the primary care provider copayment and deductible apply when applicable.

More information

More information about the state law on autism is available at www.mi.gov/autism.*

*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.

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.