Change to prior authorization process for Blue Cross commercial members in Michigan whose plans have local provider networks

Blue Cross Blue Shield of Michigan currently has one Blue Cross commercial plan in Michigan that has a local provider network. That plan is the Blue High Performance Network℠, or BlueHPN℠. Because this plan has a local provider network, providers must be in that network for services to be reimbursable.

Starting June 27, 2024, we’ll update the prior authorization process for members with BlueHPN plans to ensure that providers are in network. We’ll also do this for any Blue Cross commercial plans with local provider networks that are added in the future for members in Michigan.

Here’s what we’ll do on and after June 27 when we receive prior authorization requests for members with these plans:

1. Determine whether the treating provider is in network with the member’s plan. One of the following will happen:
• If the provider isn’t in network, we’ll deny the prior authorization request.
  

  Note: There may be some exceptions for extenuating circumstances — for example, if the member was admitted to a hospital in an emergency situation.

• If the provider is in network, the process will proceed to step 2.
2. Make a determination based on medical necessity criteria.
• If the request doesn’t meet medical necessity criteria, we’ll deny it.
• If the request meets medical necessity criteria, we’ll approve it.

Reminders

As always, it’s essential that providers check each member’s eligibility and benefits prior to performing services.

Providers are responsible for identifying the need for prior authorization through our provider portal, Benefit Explainer or Provider Inquiry and for obtaining prior authorization for services, as needed.