Blue Cross Blue Shield of Michigan and Blue Care Network require prior authorization for certain benefits. This means we need to review a service to be sure it is medically necessary and appropriate.

If a service requires prior authorization, it's important to make sure that your provider receives the prior authorization before you receive the services. If you receive those services without prior authorization, the service may not be covered. If a service isn't covered, we'll pay nothing and you may have to pay up to the full amount of the provider’s charge.

If a prior authorization is required for your medical service, your doctor or health care professional must submit the prior authorization request. Note that only your doctor or health care professional can submit the request; you will not be allowed to submit it yourself. Once we get the request and supporting medical records, we will begin the review process. 

If you're looking for more information about prescription drug prior authorization, read Why do I need prior authorization for a prescription drug?

There are four types of review for health care services:

• Prior authorization non-urgent review: When you need to get a certain health care service, but it is not urgent. It can take up to seven days for us to make our decision. This is the most common type of prior authorization request. Decisions may take longer if your provider does not submit all the information that we need to review the request. We will collaborate directly with your provider to get all the necessary information to make the best decision. 

• Prior authorization urgent review: When you need to get a certain health care service as soon as possible, but it is not an emergency. It can take up to three days for us to make our decision.

• Urgent concurrent review: When you are already getting care, your provider may ask us to approve further services to help treat you. This usually occurs after a person has been stabilized in the emergency room and needs to be admitted to the hospital for further treatment. It can take up to 24 hours for us to make our decision.

• Postservice review: When your provider submits an authorization request after you have already gotten the care you need. It can take up to 30 days for us to decide.
  

These time limits may differ for Medicare and Blue Cross and Blue Shield Federal Employment Program^® members.

If you disagree with our decision, you can appeal.

For more information on prior authorization for Michigan Education Special Services Association, or MESSA, members, visit the MESSA website.

If you have a Blue Cross Blue Shield of Michigan PPO or Blue Care Network HMO plan, our Procedure codes for which providers must request prior authorization (PDF) shows the services that require prior authorization before you receive them.

A prior authorization is not a guarantee of benefits or payment. Please check your member eligibility and benefits and medical policy coverage guidelines.

Blue Cross and BCN use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan.

The criteria to determine if a service is medically necessary can be accessed on our Medical Policy Router Search page and in additional criteria. 

Before providing services, make sure you check benefits and eligibility and medical policy coverage guidelines, using the self-service tools on Availity Essentials™. 

If you have questions, please contact Provider Inquiry from 8:30 a.m. to noon or 1 to 5 p.m., Monday through Friday:

• Professional: 1-800-344-8525
• Facility: 1-800-249-5103