Blue Cross Blue Shield of Michigan and Blue Care Network require prior authorization for certain benefits. This means we need to review a service to be sure it is medically necessary and appropriate.
If a prior authorization is required for your medical service, your doctor or health care professional must submit the prior authorization request. Once we get the request and supporting medical records, we will begin the review process.
If you have a Medicare Plus Blue℠ PPO, BCN Advantage℠ HMO or BCN Advantage℠ HMO-POS plan, our Procedure codes for which providers must request prior authorization (PDF) shows the services that require prior authorization before you receive them.
A prior authorization is not a guarantee of benefits or payment. Please check your member eligibility and benefits and medical policy coverage guidelines.
Blue Cross and BCN use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan.
Medical policies follow Medicare Advantage Medical Policy Guidelines to comply with the Centers for Medicare & Medicaid Services (CMS) Policy, National Coverage Determinations (NCDs), and /or Local Coverage Determinations (LCDs). The criteria to determine if a service is medically necessary can be accessed on our Medical Policy Router Search page and in additional criteria.
See the Medicare Coverage Database* for the most current NCD, LCD, Local Coverage Articles (LCAs) and CMS Online Manual System/Transmittals.
Blue Cross and BCN use the following:
Sign up or log in to One Healthcare ID to view InterQual criteria for inpatient services.
Blue Cross Behavioral HealthSM manages behavioral health prior authorizations and case management services for Medicare Plus Blue and BCN Advantage members. The medical necessity criteria used are the same for all members.
The following guidelines are used for all lines of business:
Before providing services, make sure you check benefits and eligibility and medical policy coverage guidelines, using the self-service tools on Availity EssentialsTM.
If you have questions, please contact Provider Inquiry from 8:30 a.m. to noon or 1 to 5 p.m., Monday through Friday:
*Blue Cross and BCN do not own or control this website.
Availity® is an independent company that contracts with Blue Cross and BCN to offer provider portal and electronic data interchange services.
Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services. For more information, go to our ereferrals.bcbsm.com website.
EviCore by Evernorth is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services. For more information, go to our ereferrals.bcbsm.com website.
TurningPoint Healthcare Solutions LLC is an independent company that manages prior authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.