Referrals & Authorizations: Blue Cross Prior Authorizations

• Summary of utilization management programs for Michigan providers
• Procedure codes for which providers must request prior authorization
• How to access the criteria used for a prior authorization determination (for non-behavioral health cases)
• Michigan providers: BCN global referral, plan notification and prior authorization requirements
• Prior authorization requirements for Michigan and non-Michigan providers for Blue Cross commercial and Medicare Plus Blue^℠
• Peer-to-peer reviews:
• How to request a peer-to-peer review with a Blue Cross or BCN medical director
• Physician peer-to-peer-request form (for non-behavioral health cases)
• Pediatric Choice:
• Requirements for BCN Pediatric Choice Program
• Routine Women's Health Benefit (formerly known as Woman's Choice:
• Routine Women's Health Benefit referral and authorization guidelines
• Routine Women's Health Benefit specialty and procedure/diagnosis code requirements
• 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. See Specialty Group NPIs (for referrals)

For Blue Cross Commercial Members only

• Federal Employee Program^® Consent for Case Management
• Prior authorization requirements for MESSA members

For Medicare Plus Blue PPO Members only

• Services That Require Authorization – Medicare Plus Blue PPO
• About Blue Dot changes to the list of Services That Require Authorization

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 .

You can find links to forms related to utilization management on our Provider Resources site. To access the forms:

1. Log in to our provider portal (availity.com).
2. Click Payer Spaces on the menu bar and then click the BCBSM and BCN logo.
3. Click the Resources tab.
4. Click Secure Provider Resources (Blue Cross and BCN).
5. Click the Forms menu and make the appropriate selection.

Note: For utilization management information for Blue Cross Complete, go to MiBlueCrossComplete.com/providers.

• Non-Michigan providers: Referral and authorization requirements for BCN members
• For Providers: Forms and Documents on bcbsm.com. This page provides access to the Waiver of Liability Statement, along with other pertinent documents and forms
• Prior authorization requirements for Michigan and non-Michigan providers for Blue Cross commercial and Medicare Plus Blue
• For Providers: What if I Don’t Participate with Medicare? on bcbsm.com. This page provides access to the Waiver of Liability Statement, along with other pertinent documents and forms