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Authorizations / Referrals
- Authorization Requirements & Criteria
- Provider Manual Chapters
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- Behavioral Health
- Blue Elect Plus POS
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- Medical Benefit Drugs
- MSU Health Plans
- Musculoskeletal Services
- Outpatient PT, OT, ST
- Pharmacy Benefit Drugs
- Sleep Management Program
- Spine Care Referral Program
Additional Resources
Authorization Requirements & Criteria
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).
Below are links to documents detailing Blue Care Network's authorization and referral requirements; 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 Pediatric Choice and Woman's Choice program information.
For drugs covered under the medical benefit, visit the Drugs Covered Under the Medical Benefit 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
- 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)
- Procedure codes that require authorization by BCN for Michigan providers (PDF)
- Non-Michigan providers: Referral and authorization requirements for BCN members (PDF)
- Acute inpatient care
- Summary of utilization management programs for Inpatient Acute Hospital Medical Admissions (PDF)
- Acute inpatient admission requests: Guidelines for submitting to BCN (PDF)
- Acute inpatient admission requests: Request for Review of Initial Inpatient Admission 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 admitted at any time and for BCN Advantage members admitted through May 31, 2019 – Post-acute care admissions: Submitting authorization requests to BCN (PDF)
- For BCN Advantage members admitted on or after June 1, 2019 – Post-acute care services: Frequently asked questions by providers (PDF)
- 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:
- BCN 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
- Laboratory: For genetic testing and molecular testing (PDF) — Includes information about our utilization management programs
- Outpatient medical rehabilitation: For authorization determinations (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
Authorization criteria and preview questionnaires
- Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
- Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
| Various procedures | |
|---|---|
| Abdominoplasty | Refer to the medical policy on Abdominoplasty (PDF) |
| Preview questionnaire (PDF) | |
| Artificial heart, total | Refer to the medical policy on Total Artificial Hearts and Implantable Ventricular Assist Devices (PDF) |
| Preview questionnaire (PDF) | |
| Bariatric surgery | Refer to the medical policy on Bariatric Surgery (Gastric Surgery for Morbid Obesity) (PDF) |
| Preview questionnaire (PDF) - for BCN HMO (commercial) members | |
| Preview questionnaire (PDF) - for BCN Advantage members | |
| Biofeedback, non-behavioral health | Refer to the medical policy on Biofeedback (PDF) |
| Preview questionnaire for BCN HMO members (PDF) | |
| Preview questionnaire for BCN Advantage members (PDF) | |
| Blepharoplasty and repair of brow ptosis | Refer to the medical policy on Blepharoplasty and Repair of Brow Ptosis (PDF) |
| Preview questionnaire (PDF) | |
| Bone-anchored hearing aid | Refer to the medical policy on Implantable Bone-Conduction and Bone-Anchored Hearing Devices (PDF) |
| Preview questionnaire (PDF) | |
| Breast implant management | Refer to the medical policy on Reconstructive Breast Surgery / Management of Breast Implants (PDF) |
| Preview questionnaire (PDF) | |
| Breast reconstruction | Refer to the medical policy on Reconstructive Breast Surgery / Management of Breast Implants (PDF) |
| Preview questionnaire (PDF) | |
| Breast reduction | Refer to the medical policy on Reduction Mammaplasty for Breast-Related Symptoms (PDF) |
| Preview questionnaire (PDF) | |
| Cardiac rehabilitation | Refer to the medical policy on Cardiac Rehabilitation, Outpatient (PDF) |
| Preview questionnaire (PDF) - for BCN HMO (commercial) members | |
| Chemical peels, dermal | Refer to the medical policy on Chemical Peels (PDF) |
| Preview questionnaire (PDF) | |
| Chemical peels, epidermal | Refer to the medical policy on Chemical Peels (PDF) |
| Preview questionnaire (PDF) | |
| Cholecystectomy (laparoscopic) | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Cosmetic or reconstructive surgery | Refer to the medical policy on Cosmetic or Reconstructive Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Deep brain stimulation | Refer to the medical policy on Deep Brain Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Dental anesthesia or immediate repair of trauma to natural teeth | Refer to the medical policy on Dental Anesthesia (PDF) |
| Refer to the medical policy on Immediate Repair of Trauma to Natural Teeth (PDF) | |
| 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) | |
| Enteral nutrition | Refer to the medical policy on Enteral Nutrition (PDF) |
| Preview questionnaire (PDF) | |
| Ethmoidectomy, endoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Excess skin removal | Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF) |
| 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 | Refer to the medical policy on Gastric Electrical Stimulation (PDF) |
| Preview questionnaire (PDF) | |
| Hammertoe correction surgery | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Hyperbaric oxygen therapy | Refer to the medical policy on Hyperbaric Oxygen Therapy – Systemic and Topical (PDF) |
| Preview questionnaire (PDF) for BCN Advantage | |
| Preview questionnaire (PDF) for BCN HMO (commercial) | |
| Medical formula for inborn errors of metabolism | Medical policy (PDF) |
| Preview questionnaire (PDF) | |
| Noncoronary vascular stents | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Not otherwise classified codes | Preview questionnaire (PDF) |
| Oral surgery | Refer to the medical policy on Oral Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Orthognathic surgery | Refer to the medical policy on Orthognathic Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Otoplasty | Refer to the medical policy on Cosmetic and Reconstructive Surgery (PDF) |
| Preview questionnaire (PDF) | |
| Pediatric feeding program | Refer to the medical policy on Pediatric Feeding Programs (PDF) |
| Preview questionnaire (PDF) | |
| Pregnancy termination | Refer to the medical policy on Pregnancy Terminations - Medical and Surgical (PDF) |
| Preview questionnaire (PDF) - for medically necessary pregnancy terminations for BCN HMO (commercial) members | |
| Preview questionnaire (PDF) - for elective pregnancy terminations for BCN HMO (commercial) members | |
| Preview questionnaire (PDF) - for medically necessary or elective pregnancy terminations for BCN Advantage members | |
| Prostatic urethral lift | Refer to the medical policy on Prostatic Urethral Lift Procedure for the Treatment of BPH (PDF) |
| Preview questionnaire (PDF) | |
| Pulmonary rehabilitation | Refer to the medical policy on Pulmonary Rehabilitation (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) | |
| Sinusotomy, frontal, endoscopic | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Sleep studies, outpatient facility and clinic-based | Refer to the medical policy on Sleep Disorders, Diagnosis and Medical Management (PDF) |
| Preview questionnaire (PDF) | |
| Surgical treatment for male gynecomastia | Refer to the medical policy on Surgical treatment for male gynecomastia (PDF) |
| Preview questionnaire (PDF) | |
| Temporomandibular joint surgery | Refer to the medical policy on Temporomandibular Joint Dysfunction (TMJD) Testing and Treatment (PDF) |
| Preview questionnaire (PDF) | |
| Varicose vein treatment | Authorization criteria (PDF) |
| Preview questionnaire (PDF) | |
| Vascular embolization or occlusion of hepatic tumors (TACE/RFA) | Refer to the medical policy on:
|
| Preview questionnaire (PDF) | |
| Ventricular assist devices | Refer to the medical policy on Total Artificial Hearts and Implantable Ventricular Assist Devices (PDF) |
| Preview questionnaire (PDF) | |
| Visual training, orthoptic and pleoptic | Refer to the medical policy on Orthoptic Training/Vision Therapy for the Treatment of Vision or Learning Disabilities (PDF) |
| 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) |
The following documents pertain to procedures for which the BCN Utilization Management department manages authorizations for dates of service prior to Jan. 1, 2021.
For dates of service on or after Jan. 1, 2021, TurningPoint Healthcare Solutions LLC manages authorization requests. See the Musculoskeletal Services page for more information about TurningPoint.
| Certain Musculoskeletal and other related Procedures, for dates of service prior to Jan. 1, 2021 | |
|---|---|
| Radiofrequency ablation, peripheral nerves | Refer to the medical policy on Radiofrequency Ablation of Peripheral Nerves to Treat Pain including Coolief Cooled RF (PDF) |
| 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.
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