Access & Training
BCN
Referrals & Authorizations
BCN Products with
Unique Requirements
Additional Resources
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 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:
- Non-emergency air ambulance prior authorization program: Overview for MI and non-MI providers (PDF)
- Air ambulance flight information (non-emergency) form (PDF)
- Air ambulance: For non-emergency flights (PDF) - Includes information about the utilization management program
- Local rules for acute care:
- Effective Aug. 1, 2023, there are no local rules for acute inpatient medical admissions of adults.
- 2022 Blue Cross and BCN Local Rules for acute inpatient medical admissions of adults care (PDF) - effective March 1, 2022, through July 31, 2023
- Local Rules for acute inpatient medical admissions of adults: Frequently asked questions (PDF) - effective March 1, 2022, through July 31, 2023
- Local rules for post-acute care (for commercial members only):
- 2023 Blue Cross and BCN Local Rules for post-acute care (PDF) - effective Aug. 1, 2023
- 2022 Blue Cross and BCN Local Rules for post-acute care (PDF) - effective Aug. 1, 2022, through July 31, 2023
- Criteria Request Form (for non-behavioral health cases) (PDF)
- Peer-to-peer reviews:
- 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.
- 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 our authorization criteria or our medical policies to make determinations on prior authorization requests for select services. To determine which services have authorization criteria and view authorization criteria and preview questionnaires, see the Authorization criteria and preview questionnaires (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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