Prenotification and Utilization Management

Blue Cross Blue Shield of Michigan uses the following pre-approval programs to help ensure appropriate and cost-effective care. The process helps identify cases that may benefit from the assistance of one of our care management programs.

We strongly recommend that you use InterQual® criteria for preadmission notification and precertification.

Preadmission notification

For continuity of care, Michigan hospitals, including Michigan hospitals with swing beds, are required to notify us when admitting a Medicare Plus Blue PPO℠ member using web-DENIS for preadmission notification.

Precertification

To make sure that the member is receiving the most appropriate care in the most appropriate setting, the following facilities are required to precertify services before admitting a Medicare Plus Blue PPO member:

  • Skilled nursing facilities
  • Inpatient rehabilitation hospitals, both freestanding rehabilitation hospitals and rehabilitation units within acute care hospitals
  • Long-term acute care hospitals

Beginning July 14, 2011 all facilities must submit precertification requests via fax to 1-866-464-8223 or via e-fax to MedicarePlusBlueFacilityFax@bcbsm.com. For information about the precertification fax process, access these helpful Fax Process FAQ (PDF). Use the appropriate form below to submit your request.

BCBSM Medicare Advantage assessment forms

All fields on the assessment form must be completed upon submission to ensure timely and efficient processing. Incomplete forms will be returned to the originating facility for completion.

Before you contact us

The proposed service must be a benefit under the patient's active contract. Check your patient's BCBSM coverage by using the web-DENIS or CAREN to verify the benefit before you fax or email your precertification request.

Preauthorization for the AIM Radiology Management Program

AIM Specialty Health preauthorizes high technology services (PDF) for BCBSM's Medicare Advantage PPO radiology management program.

Without approved preauthorization, claims will be denied and you may not bill the member.

We encourage providers to access AIM's website before scheduling to ensure the high technology service meets our criteria.

Providers should request preauthorization through AIM's website or by calling 1-800-728-8008. Note: Effective Jan. 1, 2012, AIM no longer supports order entry requests via fax. All requests submitted on or after Jan. 1, 2012, should be submitted online through AIM's ProviderPortalSM or via telephone.

Please Note: The program applies only to BCBSM Medicare Advantage PPO members receiving services from contracted providers. Non-BCBSM Medicare Advantage PPO members, non-contracted providers emergency room, observation room, inpatient services and secondary coordination of benefits are not included in this program.

Behavioral Health Services

The Behavioral Health Management program works with members and providers to coordinate mental health and substance abuse services for Medicare Plus Blue PPO individual and group members. Services include:

  • 24/7 availability of case managers
  • Comprehensive discharge planning
  • Post discharge care coordination

All mental health and substance abuse inpatient, partial hospital and intensive outpatient admissions or extensions require prior authorization and concurrent review. Acute care hospitals and behavioral health facilities that need to arrange an inpatient admission, partial hospital admission, intensive outpatient admission or concurrent review for behavioral health services must obtain prior authorization by phone at 1-888-803-4960 or via fax to 1-866-315-0442.

Learn more about care management.

Was this content helpful?

Rate it

Submit >

©1996-2014 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

Explanation of Level A Conformance
Better Business Bureau Online Seal of Reliability