New and updated e-referral questionnaires to open August 25 for BCN and Medicare Plus BlueSM PPO

Starting Aug. 25, 2019, new and updated questionnaires will open in the e-referral system for certain procedures. In addition, new and updated preview questionnaires, authorization criteria and medical policies will be available on this website.

New questionnaires

Starting August 25, questionnaires will open in the e-referral system for BCN HMOSM and BCN AdvantageSM authorization requests for the procedures listed below, which already require authorization.

Service Age Procedure codes
Bariatric surgery - BCN HMO Adult and adolescents *43644, *43645, *43770, *43771, *43772, *43773, *43774, *43775, *43842, *43843, *43845, *43846, *43847, *43848, *43886, *43887, *43888 and *44130
Bone-anchored hearing aid Adult and pediatric (5 years old and older) *69714, *69715, *69717 and *69718
Cardiac rehabilitation - BCN HMO Adult and pediatric *93797 and *93798 (for select diagnoses)
Cardiac rehabilitation - BCN Advantage
Pregnancy termination - BCN HMO Adult *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, *88304, *88305, S0190, S0191, S0199, S2260, S2265, S2266 and S2267
Pregnancy termination - BCN Advantage
Pulmonary rehabilitation Adult and pediatric G0237, G0238, G0239, G0302, G0303, G0304, G0424 and S9473
Radiofrequency ablation, peripheral nerves Adult *64640
Visual training, orthotic and pleoptic Adult and pediatric *92065

Updates to existing questionnaires

In addition, updated questionnaires will open in the e-referral system on August 25 for BCN HMO, BCN Advantage and Medicare Plus Blue authorization requests (unless otherwise noted), for the following services:

Preview questionnaires

We'll make preview questionnaires available on this website soon. To find them:

The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This will help you prepare your answers ahead of time.

Authorization criteria and medical policies

We'll also post links to the pertinent authorization criteria and medical policies on the Authorization Requirements & Criteria pages.

We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network