Referrals & Authorizations: Blue Cross Prior Authorization

• Summary of utilization management programs for Michigan providers
• Procedure codes for which providers must request prior authorization
• 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^℠
• How to access the criteria used for prior authorizations made by Blue Cross or BCN (for non-behavioral health cases)
• 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 plan notification and prior authorization guidelines
• Routine Women's Health Benefit provider specialty and procedure/diagnosis code requirements

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

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

We use pertinent medical necessity criteria to make determinations on prior authorization requests for select services. To determine which services have questionnaires and to view preview questionnaires and medical necessity criteria, see Preview questionnaires and medical necessity criteria.

You can find links to forms related to utilization management under the corresponding service page on this website and on our Provider Resources site, by logging in to our Provider Portal.

Questions? Get help accessing our Provider Portal.

• Non-Michigan providers: BCN prior authorization requirements
• 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