Use the Criteria request form to obtain criteria used in making a specific determination

When you submit an authorization request, we use medical necessity criteria — available to you on request — to make a determination on it. To obtain the criteria we used in making a determination on a specific authorization request, you’ll need to complete and submit the Criteria request form.

Here are some things to keep in mind about this form:

• Use this form for non-behavioral health authorization requests for which the Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management departments made the determination.
• Don’t use this form for determinations on authorization requests you submitted to our contracted vendors.

This form is now available for Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ requests. Previously, it was used only for BCN requests.

Follow these steps:

• Complete every field on the form.
• Fax the completed form to us at the number on the form.

You can access this form on these pages on our ereferrals.bcbsm.com website:

• Blue Cross Authorization Requirements & Criteria. Look under the Forms – Blue Cross commercial or the Forms – Medicare Plus Blue heading.
• BCN Authorization Requirements & Criteria. Look under the Referral and authorization information heading.

We’ll update our provider manuals to include information about this form.