Services That Need Prior Authorization

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 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 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.

Do you need prior authorization?

Services summary

If you have a Blue Cross Blue Shield of Michigan PPO or Blue Care Network HMO plan, our Prior Authorization Medical Services List (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.

Clinical review criteria

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 Policies page and in additional criteria. 

Additional criteria
Many procedures have unique criteria to determine coverage. Additional information on specific procedures is available in Authorization Criteria and Preview Questionnaires (PDF)

Inpatient services

Blue Cross and BCN use the nationally recognized medical necessity criteria of InterQual® for inpatient prior authorization requests. We sometimes modify InterQual® criteria for certain services. These modifications are called local rules.

For more information about modifications to the InterQual® criteria:

2024

2023

2022

Local rules for BCN behavioral health:

2023

2022

Providers can access InterQual® through Availity.

Members can access InterQual® criteria used for inpatient services by logging into their online member account and searching for prior authorization.

2024 Behavioral Health Services

Starting Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network are consolidating all behavioral health prior authorization and case management services under Blue Cross Behavioral Health. Blue Cross Behavioral Health will manage prior authorization services for commercial Blue Cross Blue Shield of Michigan, Blue Care Network, Medicare Plus Blue and BCNA members. The medical necessity criteria used will be the same for all members. 

The following guidelines will be used for all lines of business:

Outside review of prior authorization requests

Prior authorization requests for certain types of services are sometimes reviewed by outside vendors.

For more information on prior authorization requests for Blue Cross members:
For more information on prior authorization requests for BCN members:

Additional information for providers

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

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

Michigan provider prior authorization

Providers can get information on how to request a prior authorization through Availity.

You can view benefit details through Benefit Explainer. This is available on the Applications tab within the Blue Cross and BCN Payer Space on Availity.

You can review medical policy through our Medical Policy Router Search.

Non-Michigan provider prior authorization

Contact your local Blue Plan for information on how to submit a prior authorization request.

Providers may request prior authorization for MESSA members by visiting the MESSA website.

*Availity is an independent company that contracts with Blue Cross and BCN. Blue Cross and BCN do not own or control this website.

Questions?

Privacy issues: To report a concern or if you think your protected health information has been compromised, please call us at 1-800-552-8278 or email us. Don't include any protected health information in your email. 

Other issues: For customer service, call the number on the back of your member ID card.