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Changes from previous publication are identified by a Blue Dot and explained on the final page(s) of this document.BCN referral and authorization requirementsfor Michigan providersPlan notification, authorization and referral requirementsFor members with Blue Care Network commercial, BCN AdvantageSM HMO-POS and BCN AdvantageSM HMO productsFor more complete information about plan notification, authorization and referral requirements, refer to the BCN Provider Manual.BCN's Utilization Management department hours:Monday through Thursday 8:30 a.m. to 12 noon and 1 p.m. to 5 p.m.Friday 9:30 a.m. to 12 noon and 1 p.m. to 5 p.m.Telephone: 1-800-392-2512BCN's Behavioral Health department hours:Monday through Friday 8 a.m. to 5 p.m.Telephone – BCN commercial: 1-800-482-5982Telephone – BCN Advantage: 1-800-431-1059OUT-OF-STATE SERVICES: Authorization and referral requirements for out-of-state services may vary from those outlined in this document. Forinformation on requirements for out-of-state services, refer to the Non-Michigan providers: Referral and authorization requirements document orcontact BCN's Utilization Management department at 1-800-392-2512. FOR MEDICATIONS COVERED UNDER THE MEDICAL BENEFIT, SEE THE MEDICAL BENEFIT DRUGS – PHARMACY PAGE Section 1: Plan notification and authorization requirementsClick to open the list of Procedure codes that require authorization.Plan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical review on services thatrequire plan notification only. Plan notification must be submitted prior to services being provided. Authorization determinations are conducted for benefitdetermination or the application of medical necessity criteria or both. Authorization requests must be submitted prior to services being provided.Note: Thislist is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service by BCN's Utilization Management departmentbased on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may be subject to edits including,but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.General rule: For all services, noncontracted providers and providers who are not part of the designated networkassociated with the member's plan must obtain authorization from the BCN's Utilization Management department.Exception: Products such as Blue Elect PlusSM POS allow out-of-network coverage. This means that noncontracted and out-of-network providers canprovide covered services as long as they follow the authorization requirements for the services listed in the table below (for providers in Michigan) or inthe Non-Michigan providers: Referral and authorization requirements document (for providers outside of Michigan). For more details about BlueElect Plus POS, refer to BCN's Blue Elect Plus POS webpage on the ereferrals.bcbsm.com website. Blue Elect Plus POS is available Jan. 1, 2021.Note: As a rule, physicians must follow the authorization requirements that apply to the region in which the headquarters for their medical care group islocated.Note: When a procedure is to be performed by a provider not contracted with BCN, the requesting provider must complete the out-of-networkproviders questionnaire. If a questionnaire also opens for the procedure itself, the requesting provider must complete both questionnaires. Thisapplies to both BCN commercial and BCN Advantage members.ServiceRequirementsAcupunctureCovered only for BCN Advantage members. Services are eligible for reimbursement when provided according toCMS guidelines. No referral or authorization is required.AbdominoplastyAuthorization is required for all members. Must complete the abdominoplasty questionnaire.Ambulance, air For BCN commercial members: For non-emergency flights only, authorization is required from Alacura MedicalTransport Management. Fax the Air ambulance flight information (non-emergency) form to Alacura. Thencall Alacura to get the authorization number. The fax and telephone numbers for Alacura are on the form.Review the form for additional information, including the definition of a non-emergency flight. Emergency flightsdo not require authorization. For BCN Advantage members: Authorization is not required, for either emergency or non-emergency flights.Arthroscopy, kneeSee also: Musculoskeletalprocedures, otherAuthorization is required for all members. For dates of service on or after July 1, 2020, submit the requestto TurningPoint Healthcare Solutions LLC through the TurningPoint Provider Portal. Refer to BCN'sMusculoskeletal Services page at ereferrals.bcbsm.com.Artificial heart, totalAuthorization is required for all members. Must complete the artificial heart, total, questionnaire.Autism treatment: appliedbehavior analysisContact BCN's Behavioral Health department for authorization of ABA treatment visits. Treatment requires adiagnosis of autism spectrum disorder made in an evaluation done by an autism evaluation center approved byBlue Cross / BCN. See the list of approved AAECs. The behavioral health components of the evaluation do notrequire authorization. For the evaluation's medical components, the AAEC must identify each medical specialistso the primary care physician can submit a referral for each. The multidisci[plinary results must be reported onthe AAEC Evaluation Results Form and faxed to BCN. These requirements do not apply to members with BCNAdvantage products.Autism treatment: PT-OT-STservicesSee entry for physical / occupational / speech therapy in this section.Bariatric surgeryAuthorization is required for all members. Must complete either the bariatric surgery questionnaire for BCNcommercial members or the bariatric surgery questionnaire for BCN Advantage members.Effective January 2007 / Updated May 20, 2021Page 1 of 12
Changes from previous publication are identified by a Blue Dot and explained on the final page(s) of this document.BCN referral and authorization requirements for Michigan providersSection 1: Plan notification and authorization requirementsServiceRequirementsBiofeedback for urinaryincontinence and chronicconstipationAuthorization is required for all members. Attach all pertinent clinical information to the request in the e-referralsystem. Must complete either the biofeedback questionnaire for BCN commercial members or thebiofeedback questionnaire for BCN Advantage members.Note: BCN's Utilization Management staff, not the Behavioral Health staff, make the determination on therequest. Biofeedback is not covered for behavioral health diagnoses.Blepharoplasty and repair ofbrow ptosisAuthorization is required for all members. Must complete the questionnaire for blepharoplasty and repair ofbrow ptosis.Bone anchored hearing aidAuthorization is required for all members. Must complete the bone-anchored hearing aid questionnaire.Breast implant managementAuthorization is required for all members. Must complete the breast implant management questionnaire.Breast reconstructionAuthorization is required for all members. Must complete the breast reconstruction questionnaire.Breast reductionAuthorization is required for all members. Must complete the breast reduction questionnaire.Cardiac rehabilitationPlan notification is required for all members. For BCN commercial members, must complete the cardiacrehabilitation questionnaire for BCN commercial members.Cardiology proceduresSelect cardiology procedures require authorization managed by AIM Specialty Health for members of all ageswhen performed in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers andphysician offices.This applies to BCN commercial and BCN Advantage members. Refer to the list of procedurecodes that require authorization by AIM.See also: Coronarycomputed tomographyangiography (CCTA)Cervical spine surgerySee also: Musculoskeletalprocedures, otherNote: For cardiac implantable devices and services, authorization is required for dates of service on or after Jan.1, 2021.Authorization is required for all members. For dates of service on or after July 1, 2020, submit the request toTurningPoint Healthcare Solutions through the TurningPoint Provider Portal. Refer to BCN's MusculoskeletalServices page at ereferrals.bcbsm.com.Chemical peelsAuthorization is required for all members. You must complete the dermal chemical peel questionnaire orepidermal chemical peel questionnaire that opens in the e-referral system. For more information, refer to theBCN-managed procedure codes that require authorization document.Chiropractic services (spinalmanipulations) For BCN commercial members with a primary care physician in the East or Southeast region, the primary carephysician must submit a global referral. No global referral is required outside of those regions. The chiropractormust submit a plan notification, which is required even for members whose coverage allows self-referrals. For BCN Advantage members, no global referral is required in any region but the primary care physician mustsubmit a plan notification.Cholecystectomy, laparoscopicAuthorization is required for all members effective. Providers must complete the laparoscopic cholecystectomyquestionnaire.Cognitive therapyAuthorization is required for all members.Colonoscopy – virtualAuthorization is required for all members.Coronary computedtomography-angiography(CCTA)This cardiology procedure requires authorization by AIM Specialty Health for members of all ages whenperformed in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers andphysician offices.This applies to BCN commercial and BCN Advantage members. Refer to the list of procedurecodes that require authorization by AIM.Cosmetic or reconstructivesurgerySee also: Abdominoplasty;blepharoplasty and repair ofbrow ptosis; otoplasty; andrhinoplastyAuthorization is required for all members. Must complete the cosmetic or reconstructive surgeryquestionnaire.Cranial neurostimulatorpulse generator (deep brainstimulation), insertion orreplacementAuthorization is required for all members. Must complete the deep brain stimulation questionnaire.Dental anesthesia orimmediate repair of trauma tonatural teethAuthorization is required for all members. Must complete the questionnaire for dental anesthesia or repair oftrauma to natural teeth.Dental services, otherAuthorization is required for all members.Developmental delay treatmentAuthorization is required for all members.Effective January 2007 / Updated May 20, 2021Page 2 of 12
Changes from previous publication are identified by a Blue Dot and explained on the final page(s) of this document.BCN referral and authorization requirements for Michigan providersSection 1: Plan notification and authorization requirementsServiceRequirementsDiabetes suppliesWhen covered under the medical (DME) benefit, diabetes supplies for both BCN commercial and BCNAdvantage members must be obtained from J&B Medical Supply. This includes items such as continuousglucose monitors, insulin pumps and supplies, and testing supplies. Contact J&B at 1-888-896-6233 orjandbmedical.com.**Exception: Diabetic shoes and inserts are handled by Northwood for dates of service on or after June 1, 2018.See "DME and P&O."Authorization is not requred except in certain circumstances. Examples: when quantity limits are exceeded, whendocumentation is required, when the supplier is outside of the J&B network or for reasons of medical necessityoutside of the Blue Cross Inclusionary Criteria or Medicare Local Coverage Determination. In those instances,J&B will request authorization from BCN.BCN commercial members with a BCN pharmacy benefit must obtain insulin and may also obtain diabetesmonitoring products and supplies under their pharmacy benefit, through participating pharmacies. In theseinstances, no authorization is required.Diagnostic and therapeutictestsA global referral is required for BCN commercial members in the East and Southeast regions; for all othermembers, including BCN commercial members in the Mid, West and Upper Peninsula regions, no plannotification or authorization is required. No plan notification or authorization is required for members with BCNAdvantage HMO-POS.Note: For University of Michigan Premier Care, Premier Care 65 and GradCare members, and for members withMSU products and with Blue Cross Metro Detroit HMO and BCN AdvantageSM HMO ConnectedCare coverage,see exceptions to the general rule in Section 2: Referral requirements.Durable medical equipmentand prosthetics and orthotics(DME and P&O)Authorization is required for all members. Call Northwood at 1-800-393-6432 to identify a contracted supplier.The supplier submits the request to Northwood for review.Elective termination ofpregnancyAuthorization is required for all members.Electroconvulsive therapyAuthorization is required for all members.Endoscopy, uppergastrointestinal, forgastroesophageal refluxdiseaseAuthorization is required for all members. For certain diagnoses, you must complete the endoscopy for GERDquestionnaire that opens in the e-referral system. For more information, refer to the BCN-managed procedurecodes that require authorization document.Endovascular intervention,peripheral arteryAuthorization is required for all members. Must complete the endovascular intervention questionnaire.Enteral nutrition (by homeinfusion therapy providersonly)Authorization is required for all members. Must complete the enteral nutrition questionnaire.Epidural or intrathecal catheter(trial or permanent placement)Authorization is required for all members. For dates of service on or after July 1, 2020, submit the request toTurningPoint Healthcare Solutions through the TurningPoint Provider Portal. Refer to BCN's MusculoskeletalServices page at ereferrals.bcbsm.com.See also: Musculoskeletalprocedures, otherNote: As a general rule, outpatient diabetic supplies are not provided through the Northwood network. Exception:Northwood provides diabetic shoes and inserts for dates of service on or after June 1, 2018.Excess skin removalAuthorization is required for all members. Must complete the excess skin removal questionnaire.Experimental andinvestigationalAuthorization is required for all members. Must complete the experimental and investigational servicesquestionnaire.Facial and neck hair removal(for University of Michiganemployees only)Authorization is required for all members. For BCN commercial members with U-M Premier Care and U-MGradCare plans, and for certain diagnoses, you must complete the facial and neck hair removal (U-M)questionnaire that opens in the e-referral system. For more information, refer to the BCN-managed procedurecodes that require authorization document.Facial feminization surgeryand chondrolaryngoplasty(for University of Michiganemployees only)Authorization is required for all members. For BCN commercial members with U-M Premier Care andU-M GradCare plans, and for certain diagnoses, you must complete the facial feminization surgery andchondrolaryngoplasty (U-M) questionnaire that opens in the e-referral system. For more information, refer tothe BCN-managed procedure codes that require authorization document.Gastric pacing / stimulationAuthorization is required for both BCN commercial and BCN Advantage members. Must complete the gastricpacing / stimulation questionnaire.Hammertoe correction surgeryAuthorization is required for all members. For certain diagnoses, you must complete the hammertoe correctionsurgery questionnaire that opens in the e-referral system. For more information, refer to the BCN-managedprocedure codes that require authorization document.Effective January 2007 / Updated May 20, 2021Page 3 of 12
Changes from previous publication are identified by a Blue Dot and explained on the final page(s) of this document.BCN referral and authorization requirements for Michigan providersSection 1: Plan notification and authorization requirementsServiceRequirementsHome health care (by homehealth care agencies only) For BCN commercial members, home health care requires authorization only for providers not contracted withBCN. Call these requests in to BCN Utilization Management at 1-800-392-2512. For providers contracted withBCN, no authorization is required. For BCN Advantage members, home health care requires authorization through CareCentrix for episodesof care that start on or after June 1, 2021. This applies to home health agencies both inside Michigan and outsideof Michigan. Refer to the Home health care: Quick reference guide for information on how to submit priorauthorization requests. For additional information, refer to the BCN Home Health Care webpage atereferrals.bcbsm.com.Hyperbaric oxygen therapyAuthorization is required for all members. Must complete either the hyperbaric oxygen therapy questionnairefor BCN commercial members or the hyperbaric oxygen therapy questionnaire for BCN Advantagemembers.Infertility proceduresAuthorization is required for all members.Inpatient admissionsAuthorization is required for all members. Providers should notify BCN of acute non-behavioral health inpatientadmissions once the member is admitted to inpatient status and meets InterQual and BCN clinical criteria.See also: Post-acute careNote: For inpatient behavioral health admissions, refer to the Behavioral Health chapter of the BCN ProviderManual. Look in the section titled " Authorization for behavioral health services."Intensive outpatient therapy(mental health / substance usedisorders)Authorization is required for all members.Joint replacement (initial orrevision), total – hip or kneeAuthorization is required for all members, for both an initial replacement and a revision. For dates of service onor after July 1, 2020, submit the request to TurningPoint Healthcare Solutions through the TurningPoint ProviderPortal. Refer to BCN's Musculoskeletal Services page at ereferrals.bcbsm.com.See also: Musculoskeletalprocedures, otherJoint replacement (initial), total– shoulderSee also: Musculoskeletalprocedures, otherAuthorization is required for all members: For dates of service on or after July 1, 2020, submit the request toTurningPoint Healthcare Solutions through the TurningPoint Provider Portal. Refer to BCN's MusculoskeletalServices page at ereferrals.bcbsm.com.Laboratory services, geneticand molecular testingAuthorization is required for all members. Must send requests to JVHL at 1-800-445-4979.Lumbar spine surgeryAuthorization is required for all members. For dates of service on or after July 1, 2020, submit the request toTurningPoint Healthcare Solutions through the TurningPoint Provider Portal. Refer to BCN's MusculoskeletalServices page at ereferrals.bcbsm.com.See also: Musculoskeletalprocedures, otherException: No authorization is required for the Cologuard colorectal cancer screening test. This applies to both BCNcommercial and BCN Advantage members. Medical necessity criteria must still be met for the test to be eligible forreimbursement. Refer to the medical policy for information on medical necessity criteria, which states that this test isconsidered a screening technique for colorectal cancer for asymptomatic individuals at average risk who are 50 years ofage and older. Also, JVHL does not coordinate this testing and providers do not need to contact JVHL about this test.Male gynecomastia, surgicaltreatmentAuthorization is required for all male members. Must complete the surgical treatment for male gynecomastiaquestionnaire.Maternity: up to 48 hoursfollowing routine delivery / 96hours following C-sectionPlan notification is required for all members, including those whose coverage allows self-referrals.Medical formula for inbornerrors of metabolismAuthorization is required for all members. Must complete the medical formula for inborn err
members, including BCN commercial members in the Mid, West and Upper Peninsula regions, no plan notification or authorization is required. No plan notification or authorization is required for members with BCN Advantage HMO-POS. Note: For University of Michigan Premier Care, P
