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 BCN's Forms page within Provider Secured Services. To access the complete Forms Library, log in to Provider Secured Services, click BCN Provider Publications and Resources and then click Forms.
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) — Michigan and non-Michigan providers should fax the completed form using the fax numbers on the form.
- SNF/acute IPR assessment form (PDF) — Michigan providers should attach the completed form to the request in the e-referral system. Non-Michigan providers should fax the completed form using the fax numbers on the form.
Note: For BCN Advantage members admitted to post-acute care, see Post-acute care services: Frequently asked questions by providers (PDF).