Blue Care Network requires prior authorization for certain procedures to ensure that members get the right care at the right time and in the right location.

For BCN commercial members only, we require plan notification for certain services. Plan notification alerts BCN to a scheduled service and facilitates claims payment (clinical review isn’t needed). Providers must follow the requirements that apply to the region in which their medical care group’s headquarters is located:

• In the East and Southeast regions, providers must submit plan notification to BCN through the e-referral system.
• In the Mid, West and Upper Peninsula regions, plan notification isn’t required so providers don’t need to submit anything in the e-referral system.

Health care providers must submit both prior authorization requests and plan notifications before providing services. See the e-referral User Guide to learn how.

Authorization Information

• Summary of utilization management programs for Michigan providers (PDF)
• Procedure codes for which providers must request prior authorization (PDF)
• Michigan providers: BCN global referral, plan notification and prior authorization requirements (PDF)
• How to access the criteria used for a prior authorization determination (for non-behavioral health cases) (PDF)
• Peer-to-peer reviews:
• How to request a peer-to-peer review with a Blue Cross or BCN medical director (PDF)
• Physician peer-to-peer-request form (for non-behavioral health cases) (PDF)
• Pediatric Choice: Requirements for BCN Pediatric Choice Program (PDF)
• Routine Women's Health Benefit (formerly known as Woman's Choice):
• Routine Women's Health Benefit referral and authorization guidelines (PDF)
• Routine Women's Health Benefit specialty and procedure/diagnosis code requirements (PDF)
• Referrals to the University of Michigan Health System and Henry Ford Health System — Referrals to these two health systems require using specialty group NPIs rather than referring to an individual practitioner. See Specialty Group NPIs (for referrals) (PDF)

Preview questionnaires and medical necessity criteria for select services

We use pertinent medical necessity criteria to make determinations on prior authorization requests for select services. To determine which services have questionnaires and to view preview questionnaires and medical necessity criteria, see the document Preview questionnaires and medical necessity criteria (PDF).

Utilization management forms

You can find links to forms related to utilization management on our Provider Resources site. To access the forms:

1. Log in to our provider portal (availity.com*).
2. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
3. Click the Resources tab.
4. Click Secure Provider Resources (Blue Cross and BCN).
5. Click the Forms menu and make the appropriate selection.

Documents and forms for noncontracted or non-Michigan providers

• Non-Michigan providers: Referral and authorization requirements for BCN members (PDF)
• For Providers: Forms and Documents page on bcbsm.com. This page provides access to the Waiver of Liability Statement, along with other pertinent documents and forms

Note: For utilization management information for Blue Cross Complete, go to MiBlueCrossComplete.com/providers.

* 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.