Timely clinical information is key to receiving faster responses on authorization requests

We’ve received complaints from members that it sometimes takes too long for their services to be authorized by Blue Cross Blue Shield of Michigan, Blue Care Network or by a company we’re working with to provide utilization management decisions for certain procedures.

Keep in mind that the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services require Blue Cross and BCN to respond to authorization requests within certain time frames.

We’re working to improve our response times and ask for your help to prevent an authorization request from being delayed or denied. It’s important that health care providers respond quickly to requests for documentation to prevent a delay of necessary or urgent medical services for members. We require clinical information for authorization requests to ensure that we make a timely and appropriate decision. Companies we work with to manage certain procedures may also ask providers for clinical information to support your requests.

It’s important that you provide requested clinical information and other documentation within the designated time frame indicated in the correspondence from Blue Cross, BCN or the company we’re working with to handle utilization requests.

Clinical information includes relevant information regarding a member’s:

• Health history
• Physical assessment
• Test results
• Consultations
• Previous treatment

We recommend that you’re prepared with clinical information at the time you submit your request in the event you’re asked to provide it. Much of the follow‑up information that we request is found on the questionnaires on erefferals.bcbsm.com. You can find preview questionnaires with links to related authorization criteria or medical policies on these webpages:

• BCN Authorization Requirements & Criteria
• Blue Cross Authorization Requirements & Criteria

Companies we work with that manage certain utilization management programs usually have their own versions of these questionnaires.

The most efficient way to provide clinical information for programs managed by Blue Cross and BCN is through the e‑referral system. Use the Case Communication section to document how the patient meets clinical criteria.

For more information about utilization review, refer to our provider manuals. Here’s how to find them:

1. Log in as a provider at bcbsm.com.
2. Click on Provider Manuals on the lower right side of the screen.
3. Select the manual you want to review.

The Utilization Management chapter of the BCN Provider Manual is also posted on ereferrals.bcbsm.com. You can get there without logging in. Click on Provider Manual Chapters under BCN Authorizations/Referrals in the left‑hand column.