Starting July 25, we'll use clinical information to validate providers' answers to some questionnaires in the e-referral system

Starting July 25, 2021, we'll pend some authorization requests that would usually be auto-approved based on your answers to the questionnaires in the e-referral system. This will allow us to validate the answers you provided on the questionnaire.

This applies to authorization requests submitted for BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members.

When we pend a request, you'll get this message in the e-referral system: “Case requires validation. Medical records required. Please attach clinical information from the patient's medical record applicable to this request in the Case Communication field.”

For instructions on how to attach clinical information to the authorization request in the e-referral system, refer to the e-referral User Guide (PDF). Look in the section titled "Create New (communication)."

When we receive the clinical information, we'll review it to confirm that it supports the information you provided in the questionnaire and then we'll make a determination on the request.

If we don't receive the clinical information or if the clinical information you send doesn't support your answers in the questionnaire, we won't be able to approve the request.

As a reminder, on the preview questionnaires that we publish on this website, we state that we will retrospectively monitor compliance with this authorization requirement. You can access the preview questionnaires:

Note: This change was originally scheduled to take place in June, which we communicated in March 2021 via a web-DENIS message and a news item on this website and in May through articles in our provider newsletters.

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network