Preauthorization and Utilization Management

Blue Cross Blue Shield of Michigan uses the following precertification, and preauthorization programs to ensure that our network doctors and hospitals provide the most appropriate and cost-effective care. Clinical necessity and criteria help identify cases that may benefit from the assistance of one of our care management programs.

We strongly recommend that you use InterQual® clinical criteria for preauthorization of hospital admissions to determine the medical necessity of hospital admissions before you call for authorization.


For continuity of care, Michigan hospitals, including Michigan hospitals with swing beds, are required to submit a preauthorization request through e-referral when admitting a Medicare Plus BlueSM PPO member.


To make sure that the member is receiving the most appropriate care in the most appropriate setting, the following facilities are required to precertify services before admitting a Medicare Plus Blue PPO member:

  • Skilled nursing facilities
  • Inpatient rehabilitation hospitals, both freestanding rehabilitation hospitals and rehabilitation units within acute care hospitals
  • Long-term acute care hospitals

Skilled nursing, inpatient rehabilitation and long-term acute care for Michigan providers

Effective June 1, 2016, send precertification requests for skilled nursing, long-term acute care and inpatient rehab facilities for Michigan residents and members to eviCore Healthcare.

Call 1-877-917-2583. Contact them Monday through Friday, 7 a.m. to 8 p.m. On weekends and holidays, from 10 a.m. to 5 p.m.

Skilled nursing, inpatient rehabilitation and long-term acute care for non-Michigan providers and members

Precertification requests for skilled nursing, long-term acute care and inpatient rehab facilities for members who don't reside in Michigan should continue to complete the appropriate facility request form.

Fax your request to 1-866-464-8223, or email Contact them Monday through Friday, 8 a.m. to 6 p.m. You can send a fax at any time. 

For information about the precertification fax process, read the Fax Process FAQ (PDF). Use the appropriate form below to submit your request.

BCBSM Medicare Advantage assessment forms

All fields on the assessment form must be completed upon submission to ensure timely and efficient processing. Incomplete forms will be returned to the originating facility for completion.

Before you contact us

The proposed service must be a benefit under the patient's active contract. Check your patient's BCBSM coverage by using the web-DENIS or PARS to verify the benefit before you fax or email your precertification request.

Prior authorizations for other services

  • Physical therapy and occupational therapy - effective Jan. 1, 2017
    Please Note: Skilled nursing facilities providing physical and occupational therapy do not need to obtain prior authorization.
  • Radiation therapy services - effective Nov. 1, 2016
  • Lumbar spinal fusion surgery and interventional pain management services - effective Sept. 1, 2016

Prior authorization is not required for Blue Cross® Medicare Private Fee for Service members, but providers or members can request it if they want. 

The Medicare Plus Blue prior authorization codes list (PDF) represents procedures that require authorization by eviCore healthcare for Medicare Plus Blue PPO members who reside in Michigan and receive services from Michigan providers. Providers must obtain authorization from eviCore before these services are provided.

Send your requests to eviCore healthcare by calling 1-877-917-2583. Contact them Monday through Friday, 7 a.m. to 8 p.m. On weekends and holidays, contact them from 10 a.m. to 5 p.m. See our guidelines (PDF) for more information.  

Preauthorization for the AIM Radiology Management Program

AIM Specialty Health preauthorizes high technology services (PDF) for BCBSM's Medicare Advantage PPO radiology management program.

Without prior approval, claims will be denied and you may not bill the member.

We encourage providers to access AIM's website before scheduling to ensure the high technology service preauthorization was obtained.

Providers should request prior approval through AIM's website or by calling 1-800-728-8008. Submit all requests online through AIM's ProviderPortalSM or via telephone. 

Please Note: The program applies only to BCBSM Medicare Advantage PPO members receiving services from contracted providers. Non-contracted providers, emergency room, observation room, inpatient services and secondary coordination of benefits are not included in this program.

Behavioral Health Services

The Behavioral Health Management program works with members and providers to coordinate mental health and substance use disorder services for Medicare Plus Blue PPO individual and group members. Services include:

  • 24/7 availability of case managers
  • Comprehensive discharge planning
  • Post discharge care coordination

Beginning Jan. 1, 2016, we'll use McKesson’s InterQual criteria to assess the medical necessity of all behavioral health inpatient, partial hospitalization and intensive outpatient admissions for psychiatric or chemical dependency treatments.

All mental health and substance use disorder inpatient, partial hospital and intensive outpatient admissions or extensions require prior authorization and concurrent review. Acute care hospitals and behavioral health facilities that need to arrange an inpatient admission, partial hospital admission, intensive outpatient admission or concurrent review for behavioral health services must obtain prior authorization by phone at 1-888-803-4960 or via fax to 1-866-315-0442.

Learn more about care management.