Below are links to various utilization-management-related forms, some of which are used to request authorization for various services. These forms are also available, along with others, on our Provider Resources site. To access the forms:
- Log in to our provider portal (availity.com*).
- Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
- Click the Resources tab.
- Click Secure Provider Resources (Blue Cross and BCN).
- Click the Forms menu and make the appropriate selection.
Skilled nursing facilities and home health agencies
Hospitals, for patients in observation
Hospitals, for inpatients
- Waiver of Liability (PDF)
- Patient Assessment Form (PDF)
Behavioral health services
Drugs covered under the medical benefit
For information about drugs covered under the medical benefit, visit the Medical Benefit Drugs – Pharmacy page on this website.
Transitional care services
- LTACH assessment form (PDF) — for commercial members only
- SNF/acute IPR assessment form (PDF) — for commercial members only
Note: For BCN Advantage members admitted to post-acute care, see Post-acute care services: Frequently asked questions by providers (PDF).
*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.