Prenotification 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 prenotification of hospital admissions, preauthorization, and precertification 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 notify us when admitting a Medicare Plus Blue℠ PPO member using web-DENIS for preadmission notification.
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
Beginning July 14, 2011 all facilities must submit precertification requests via fax to 1-866-464-8223 or via e-fax to MedicarePlusBlueFacilityFax@bcbsm.com. For information about the precertification fax process, access these helpful Fax Process FAQ (PDF). Use the appropriate form below to submit your request.
BCBSM Medicare Advantage assessment forms
- Medicare Plus Blue PPO skilled nursing facility, acute rehabilitation facility fax assessment form (PDF)
- Medicare Plus Blue PPO LTACH fax assessment form (PDF)
- Medicare Plus Blue PPO expedited/urgent admission fax assessment form (PDF)
- Medicare Plus Blue PPO non-Michigan acute inpatient fax assessment form (PDF)
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.
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 abuse 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 abuse 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.