Referrals & Authorizations: BCN Prior Authorization & Plan Notification

Blue Cross Blue Shield of Michigan and Blue Care Network require prior authorization for certain procedures to ensure that members get the right care at the right time and in the right location.

For BCN commercial members only, we require plan notification for certain services. Plan notification alerts BCN to a scheduled service and facilitates claims payment (clinical review isn't needed). Providers must follow the requirements that apply to the region in which their medical care group's headquarters is located:

In the East and Southeast regions, providers must submit plan notification to BCN through the e-referral system.
In the Mid, West and Upper Peninsula regions, plan notification isn't required so providers don't need to submit anything in the e-referral system.

Health care providers must submit both prior authorization requests and plan notifications before providing services. For more information, see the e-referral User Guide.

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Prior authorization information

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^SM
Peer-to-peer reviews:

Pediatric Choice:

Requirements for BCN Pediatric Choice Program

Routine Women's Health Benefit (formerly known as Woman's Choice:

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

For Medicare Plus Blue PPO Members only

Prior authorization criteria and preview questionnaires for select services

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 .

Utilization management forms

You can find links to forms related to utilization management 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.

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

Documents and forms for noncontracted or non-Michigan 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