Services That Need Approval

Blue Cross Blue Shield of Michigan and Blue Care Network need to review and approve some of your health care services. The services that need approval depend on if you have a PPO, EPO or HMO plan.

Blue Cross Blue Shield of Michigan PPO and EPO plans

Depending on the health care service you receive, your provider might have to get our approval for coverage of that service.

Here are the stages of your care that our approval could happen.

  • Preservice review: Your provider will have to get our approval for your health care services before you receive them. Approval happens most often during this stage.
  • Urgent concurrent review: These reviews happen when you're in the process of receiving health care services. This can happen when you're already at the doctor or in the emergency room.
  • Postservice review: This approval happens after you've received your health care services.
If you disagree with our decision, you can appeal.

You'll need to be sure that your plan covers your health care services and that your coverage is active at the time you receive treatment. When we review your services, that doesn't guarantee payment of your claims. 

Here are the services that need approval.

  • Some radiology services: 
    • CT
    • CTA
    • Echocardiology
    • MRI
    • MRA
    • MRS
    • nuclear cardiology
    • PET
    • QCT bone densitometry
  • Inpatient care:
    • Acute
    • Mental health care including residential psychiatric admissions
    • Substance abuse treatment
  • In-lab sleep studies
  • Skilled nursing care
  • Human organ transplant services
  • Rehabilitation therapy
  • Applied behavioral analysis
  • repetitive Transcranial Magnetic Stimulation (rTMS)

Blue Care Network HMO plans

Blue Care Network needs to review and approve some health care services before you receive them.

  • Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen
  • Physical therapy, speech therapy and occupational therapy
  • Weight-reduction procedures
  • Bone marrow transplants
  • Infertility services
  • Breast reduction
  • Durable medical equipment
  • Services from out-of-network physicians or health care professionals
  • Procedures that may be experimental or investigational

 

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