Medicare Advantage 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. Once we get the request and supporting medical records, we will begin the review process. 

Do you need prior authorization?

Services summary

If you have a Medicare Plus Blue PPO, BCN Advantage HMO or BCN Advantage HMO-POS 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, post acute, home health care and select outpatient prior authorization requests.

For more information about modifications to the InterQual® criteria:

  • 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.

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.com

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

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

Still need help?

We're just a phone call away.

Contact us

Was this helpful?

Let us know if we answered your question.