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October 2021

What you need to know about doing business with Blue Cross

We publish an article on this topic annually to help ensure our providers have the information they need to do business with us.

There’s certain information our participating providers need to know about doing business with Blue Cross Blue Shield of Michigan. This article provides a summary of key information.

Online provider manuals — Important information you need to do business with Blue Cross is included in our online provider manuals. To access them, click on Provider Manuals in the left-hand column of the homepage of web-DENIS.

Access and availability guidelines — When a member requests an appointment, Blue Cross providers are required to comply with the following standards.

Access to primary care
  • Regular and routine care — within 30 business days
  • Urgent care — within 48 hours
  • After-hours care — 24 hours, seven days a week
Access to behavioral health care
  • Life-threatening emergency — within one hour or by having a policy to direct members to nearest emergency services.
  • Not life-threatening emergency — within six hours
  • Urgent care — within 48 hours
  • Initial visit for routine care — within 10 business days
  • Follow-up routine care — within 30 business days of request
Access to specialty care

High-volume specialist, including, but not limited to:

OB-GYN and high-impact specialist (oncologist)

  • Regular and routine care — within 30 business days
  • Urgent care — within 48 hours

For more detailed information, see the “PPO Policies” chapter in the provider manual.

Affirmative statement about incentives — Medical decisions are based only on appropriateness of care and service and existence of coverage. See the affirmation statement in the “Participation” chapter of the provider manual. It’s located in the section titled Requirements and Guidelines.

Clinical practice guidelines — For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found on the mqic.org** website.

Comprehensive care management — To learn about Blue Cross’ comprehensive care management program and how to refer our members to the program, check out the “Case management” section of the Blue Pages Directory in your online provider manual. To find the information on bcbsm.com, click on the Providers tab and type Blue Cross Coordinated Care in the search field. Scroll down to For Providers: Blue Cross Coordinated Care.

Criteria used for level of care utilization management decisions

For hospitals and facilities, Blue Cross uses InterQual criteria to assess medical necessity and the appropriate level of care. Criteria encompasses acute care (adult and pediatric), rehabilitation (adult and pediatric), long-term acute care, skilled nursing facility and home health care.

Blue Cross modifications of the InterQual criteria (local rules) can be accessed online by following these steps:

  • Log in to web-DENIS.
  • Click on BCBSM Provider Publications and Resources.
  • Click on Newsletters & Resources.
  • Click on Clinical Criteria & Resources.

If you have questions about InterQual, send an email to CESupport@mckesson.com. Provide your name and address and reference that the question pertains to InterQual.

Note: Criteria for Blue Cross and Blue Shield Federal Employee Program® utilization management decision-making can be found at fepblue.org.

Medical policies

To review additional Blue Cross medical policies, go to bcbsm.com/providers.

  • Click on Quick Links.
  • Click on Preauthorization and precertification.
  • Click on Medical policy, precertification and preauthorization router.
  • Use the button to select Medical Policy, then follow online prompts.

FEP policies can be found at fepblue.org.

Member rights and responsibilities

Blue Cross outlines the rights and responsibilities of our members, including how members can file a complaint or grievance. Go to the Important Information page on our website and click on Learn More under Rights and responsibilities for more information.

Pharmacy management

It’s important for you to be familiar with our drug lists and our pharmacy management programs, such as step therapy, quantity limits, dose optimization, use of generics and specialty pharmacy. You also need to know how to request prior authorization and the information needed to support your request.

Note: Generic substitution may be required for Blue Cross members. If both the generic and brand name are listed on our drug list, members are encouraged to receive the generic equivalent when available. Some members may be required to pay the difference between the brand-name and generic drug, as well as applicable copay, depending on the member’s plan.

See the Pharmacy Services page on our website for more details. We recommend that you visit this page at least quarterly to access our drug lists and view updates. Go to bcbsm.com/providers. You can also call 1-800-437-3803 for the most up-to-date pharmaceutical information.

Translation services

Members who need language assistance can call the Customer Service number on the back of their member ID card. TTY users should call 711.

Utilization management staff availability

Department telephone numbers and hours are shown in the “Preapproval Decisions/Utilization Management Decisions” section of the “Appeals and problem resolution chapter” of the provider manuals.

Behavioral health care — New Directions

New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross. For information on the New Directions Behavioral Health Quality Improvement Program, click here.**

Contact information:

  • Commercial (PPO and Traditional) programs: 1-800-762-2382
  • Federal Employee Program: 1-800-342-5891
  • United Auto Workers Retiree Medical Benefits Trust, or URMBT: 1-877-228-3912
  • MESSA: 1-877-866-2395
  • GM salaried: 1-877-240-0705
  • State of Michigan: 1-866-503-3158
Behavioral health criteria New Directions medical necessity criteria for behavioral health admissions are reviewed annually and updated as needed. Providers may download the criteria at ndbh.com** or request a printed copy by contacting New Directions. Providers may also view or print this information by accessing it via web-DENIS.
Behavioral health member rights and responsibilities For members’ behavioral health services rights and responsibilities, click here.**
Behavioral health statement about incentives Decisions about utilization of behavioral health services are made on the basis of eligibility, coverage and appropriateness of care and services. New Directions doesn’t specifically reward, hire, promote or terminate practitioners or other individuals for issuing denials of coverage. Utilization decision-makers don’t receive incentives that would result in under-utilization.

For more information


  • Information about our programs and additional resources are available on the Important Information page of our website.
  • To request a printed copy of any of the information contained in this article, call HCV Quality Management at 248-455-2808.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.