
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 to our provider portal (availity.com)*.
- Click Payer Spaces on the Availity menu bar.
- Click the BCBSM and BCN logo.
- Click Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
- Click Coronavirus on the Member Care tab.
Below are links to documents detailing Blue Care Network's authorization and referral requirements for services managed by BCN, including lists of procedures that require authorization and authorization criteria and preview questionnaires for various procedures. These apply to services other than drugs covered under the medical benefit. In addition, there are links to information about the Pediatric Choice and Woman's Choice programs.
For drugs covered under the medical benefit, visit the Medical Benefit Drugs page in the BCN section of this website.
For Blue Cross Complete utilization management information, go to MiBlueCrossComplete.com/providers.
Referral and authorization information
- Summary of utilization management programs for Michigan providers (PDF)
- Authorization requirements documents
- Procedure codes for which Michigan and non-Michigan providers must request prior authorization (PDF)
- BCN referral and authorization requirements for Michigan providers (PDF)
- About Blue Dot Changes to the BCN referral and authorization requirements document for Michigan providers (PDF)
- BCN-managed procedure codes that require authorization for Michigan providers (PDF)
- Non-Michigan providers: Referral and authorization requirements for BCN members (PDF)
- Acute inpatient care
- Submitting acute inpatient authorization requests: Frequently asked questions for providers (PDF)
- For BCN commercial members – Acute inpatient hospital assessment form (PDF)
- For BCN Advantage members – Medicare Advantage inpatient assessment form (PDF)
- Guidelines for bundling admissions (PDF)
- Inpatient medical admissions, acute care (hospitals): For authorization determinations (PDF) - Includes information about our utilization management program
- Post-acute care:
- For BCN commercial members – Post-acute care admissions: Submitting authorization requests (PDF)
- For BCN Advantage members – 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
- Holiday closures: How to submit authorization requests for inpatient admissions (PDF)
- Air ambulance authorization requests for BCN commercial members:
- 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
- BCN's Local Rules:
- 2022 Blue Cross and BCN Local Rules for acute care (PDF)
- Local Rules for acute care: Frequently asked questions (PDF)
- 2023 Blue Cross and BCN Local Rules for post-acute care (PDF) - for commercial members only
- 2022 Blue Cross and BCN Local Rules for post-acute care (PDF) - for commercial members only
- BCN's Local Rules effective Aug. 2, 2021, through July 31, 2022 (PDF)
- Criteria Request Form (for non-behavioral health cases) (PDF)
- Peer-to-peer reviews:
- Cardiology: For home monitoring and cardiology and echocardiology procedures (PDF)- Includes information about care management and utilization management programs
- Chiropractic services: For chiropractic manipulations and physical medicine services by chiropractors (PDF) — Includes information about utilization management programs
- 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) — Includes information about care management and utilization management programs
- Elective procedures and services: For authorization determinations (PDF) — Includes information about care management and utilization management programs
- Laboratory: For genetic testing and molecular testing (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
Authorization criteria and preview questionnaires
We use either our authorization criteria or our medical policies to make determinations on prior authorization requests for the services listed below. To view these items:
- To view authorization criteria, click the “Authorization criteria” link to the right of the service below. If there isn’t a link to an authorization criteria document, we’ll use the pertinent medical policy to make the determination.
- To view a medical policy, open our Medical Policy Router Search page on bcbsm.com. Enter a procedure code in the Policy/Topic Keyword field to search for the pertinent policy.
Various procedures | |
---|---|
Abdominoplasty | Preview questionnaire (PDF) |
Ambulatory event monitors, implantable | Preview questionnaire (PDF) - for BCN commercial members |
Preview questionnaire (PDF) – for BCN Advantage members | |
Biofeedback, non-behavioral health | Preview questionnaire (PDF) - for BCN commercial members |
Preview questionnaire (PDF) - for BCN Advantage members | |
Blepharoplasty and repair of brow ptosis | Preview questionnaire (PDF) |
Bone-anchored hearing aid | Preview questionnaire (PDF) |
Breast elastography | Preview questionnaire (PDF) |
Breast implant management | Preview questionnaire (PDF) — for BCN commercial members |
Preview questionnaire (PDF) — for BCN Advantage members | |
Breast reconstruction | Preview questionnaire (PDF) — for BCN commercial members |
Breast reduction | Preview questionnaire (PDF) – for BCN commercial members |
Preview questionnaire (PDF) – for BCN Advantage members | |
Chemical peels, dermal | Preview questionnaire (PDF) |
Chemical peels, epidermal | Preview questionnaire (PDF) |
Cosmetic or reconstructive surgery | Preview questionnaire (PDF)) |
Deep brain stimulation | Preview questionnaire (PDF) |
Dental anesthesia or immediate repair of trauma to natural teeth | Preview questionnaire (PDF) |
Endoscopy, upper gastrointestinal, for gastroesophageal reflux disease | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Endovascular intervention, peripheral artery | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Endovenous ablation for treatment of varicose veins | Preview questionnaire (PDF) |
Enteral nutrition | Preview questionnaire (PDF) |
Ethmoidectomy, endoscopic | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Excess skin removal | Preview questionnaire (PDF) |
Experimental and investigational services | Preview questionnaire (PDF) |
Facial and neck hair removal (for University of Michigan employees only) | Preview questionnaire (PDF) |
Facial feminization surgery and chondrolaryngoplasty (for University of Michigan employees only) | Preview questionnaire (PDF) |
Gastric pacing / stimulation | Preview questionnaire (PDF) |
Hammertoe correction surgery | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Hyperbaric oxygen therapy | Preview questionnaire (PDF) for BCN Advantage |
Preview questionnaire (PDF) for BCN commercial | |
Left atrial appendage closure | Preview questionnaire (PDF) - for BCN commercial members |
Preview questionnaire (PDF) - for BCN Advantage members | |
Medical formula for inborn errors of metabolism | Preview questionnaire (PDF) |
Noncoronary vascular stents | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Not otherwise classified codes | Preview questionnaire (PDF) |
Oral surgery | Preview questionnaire (PDF) |
Orthognathic surgery | Preview questionnaire (PDF) |
Otoplasty | Preview questionnaire (PDF) |
Pediatric feeding program | Preview questionnaire (PDF) |
Pregnancy termination | Preview questionnaire (PDF) - for medically necessary pregnancy terminations for BCN commercial members |
Preview questionnaire (PDF) - for elective pregnancy terminations for BCN commercial members | |
Preview questionnaire (PDF) - for medically necessary or elective pregnancy terminations for BCN Advantage members | |
Prostatic urethral lift | 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) | |
Responsive neurostimulator/deep brain stimulation trigger | Preview questionnaire (PDF) |
Responsive neurostimulation for the treatment of refractory partial epilepsy | Preview questionnaire (PDF) |
Rhinoplasty | Preview questionnaire (PDF) |
Sacral nerve neuromodulation/stimulation | Preview questionnaire (PDF) |
Septoplasty | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Sinusotomy, frontal, endoscopic | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Sleep studies, outpatient facility and clinic-based | Preview questionnaire (PDF) |
Surgical treatment for male gynecomastia | Preview questionnaire (PDF) |
Temporomandibular joint surgery | Preview questionnaire (PDF) |
Thyroidectomy, partial | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Thyroidectomy, total | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Varicose vein treatment | Authorization criteria (PDF) |
Preview questionnaire (PDF) | |
Vascular embolization or occlusion of hepatic tumors (TACE/RFA) | Preview questionnaire (PDF) |
Visual training, orthoptic and pleoptic | Preview questionnaire (PDF) |
Out-of-network providers — For prior authorization requests for procedures to be completed by providers who aren’t contracted with BCN | Preview questionnaire (PDF) |
Pediatric Choice
Woman's Choice
The Woman's Choice program allows BCN members to directly access affiliated physicians who perform obstetric or gynecologic services. In line with Woman's Choice guidelines, an obstetrician-gynecologist may perform or order some services without a referral from the primary care physician.
* 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 required to let you know we're not responsible for its content.