New U.P. Blue Referral Form available for Upper Peninsula Blue^SM members

Blue Cross Blue Shield of Michigan revised the U.P. Blue Referral Form for Upper Peninsula Blue^SM members.

It now offers a simple one-page form and a new fax number for submitting the document. You can download and print the U.P. Blue Referral Form by clicking here.

Please immediately discontinue using the TRUST PPO/POS Program Referral Form and the UP Blue Out-of-State Preauthorization Form.

Remember to follow these procedures when referring a UP Blue member to an out-of-state provider:  

• Complete the referral before the member receives services from an out-of-state provider.
• Complete the U.P. Blue Referral Form for applicable UP Hospital Blue members within the tier networks.
• Retrospective referrals will not be approved without documentation from the patient’s medical record indicating the referral was initiated prior to the UP Blue member receiving the services.
• Fax the U.P. Blue Referral Form and supporting documentation to the Upper Peninsula Health Plan at 906-225-9268. Note: This is a new fax number.
• The Upper Peninsula Health Plan will notify the referring provider of the decision or need for additional information by fax within 48 hours.
• UPHP will fax the final decision about the referral to the BCBSM Marquette office so that the member can be sent a letter notifying him or her of the decision.
• It is the member’s responsibility to monitor and request that his or her claims be reprocessed at his or her plan’s designated PPO benefit level if they choose to do so.