Services That Need Approval

Blue Cross Blue Shield of Michigan and Blue Care Network need to review and approve some of your health care services. That's called prior authorization. The services that need approval depend on if you have a PPO, EPO or HMO plan.

If you're looking for more information about prescription drug prior authorization, read Why do I need prior authorization for a prescription drug?

Depending on the health care service you receive, your provider might have to get our approval for coverage of that service.

Approval can be requested at any of these stages:

  • Preservice review: Your provider will have to get our approval for your health care services before you receive them. Approval happens most often during this stage.
  • Urgent concurrent review: These reviews happen when you're in the process of receiving health care services. This can happen when you're already at the doctor or in the emergency room.
  • Postservice review: This approval happens after you've received your health care services.

If you disagree with our decision, you can appeal.

You'll need to be sure that your plan covers your health care services and that your coverage is active at the time you receive treatment. If you don't get prior authorization when it's needed, we might not pay your claim. When we review your services, that doesn't guarantee payment of your claims. Sometimes, we need to review to be sure the service is necessary and appropriate for your situation.

Here are some services that need approval. This is not a full list. 

  • Some radiology services: 
    • CT
    • CTA
    • Echocardiology
    • MRI
    • MRA
    • MRS
    • nuclear cardiology
    • PET
    • QCT bone densitometry
  • Inpatient care:
    • Acute
    • Mental health care including residential psychiatric admissions
    • Substance abuse treatment
  • In-lab sleep studies
  • Skilled nursing facility care
  • Human organ transplant services
  • Rehabilitation therapy
  • Applied behavioral analysis
  • repetitive Transcranial Magnetic Stimulation (rTMS)
  • Gender reassignment surgery
  • Freestanding substance abuse facilities

Blue Care Network HMO members

If you have an HMO plan, there are some additional services you'll need approval for. Here are some examples:

  • Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen
  • Physical therapy, speech therapy and occupational therapy
  • Weight-reduction procedures
  • Bone marrow transplants
  • Infertility services
  • Breast reduction
  • Durable medical equipment
  • Services from out-of-network physicians or health care professionals
  • Procedures that may be experimental or investigational
  • Genetic testing
  • Outpatient mental health and substance abuse services
  • Sleep studies (any outpatient setting)
  • Cardiology procedures
  • Radiation therapy
  • Spine injections
  • Knee arthroscopies
imp-info

Questions?

Privacy issues: To report a concern or if you think your protected health information has been compromised, please call 1-800-482-3787 or email privacy@bcbsm.com. Don't include any protected health information in your email. 

Other issues: For customer service, call the number on the back of your member ID card or 1-313-225-9000.

©1996-2016 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. We provide health insurance in Michigan.

State and Federal Privacy laws prohibit unauthorized access to Member's private information. Individuals attempting unauthorized access will be prosecuted.

Site Map  |  Feedback  |  Important Legal and Privacy Information

1x
Better Business Bureau Online Seal of Reliability