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 preauthorization 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 facilities
  • 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.

For members admitted on or after June 1, 2019: Authorization requests for post-acute care services will be managed by naviHealth. See the frequently asked questions (PDF) for more information. 

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.

For members admitted on or after June 1, 2019: Authorization requests for post-acute care services will be managed by naviHealth. See the frequently asked questions (PDF) for more information. 

Medicare Plus Blue PPO 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

  • Lumbar spinal fusion surgery and interventional pain management services – effective Sept. 1, 2016
  • Musculoskeletal surgical procedures excluding lumbar spinal fusion – effective July 1, 2020 
  • 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

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.  

Authorization of musculoskeletal surgical procedures excluding lumbar spinal fusion – TurningPoint

For dates of service on and after July 1, 2020, TurningPoint Healthcare Solutions, LLC will manage inpatient and outpatient authorizations for musculoskeletal surgical procedures for Medicare Plus BlueSM PPO members. This includes joint replacement surgeries and other related procedures. See the Musculoskeletal services page for a list of the orthopedic codes that require authorization from TurningPoint. Providers were able to submit authorization requests to TurningPoint starting June 1, 2020.

Note: eviCore will continue to manage lumbar spinal fusion surgeries for Medicare Plus Blue members throughout 2020.

Retrospective Requests: Providers can submit retrospective requests for up to 90 days after the procedure is performed.

Providers can request an authorization through the TurningPoint provider portal, accessed by logging in to Provider Secured Services at When authorization is received, provide the appropriate facility with the authorization number.

Out-of-state providers: Register with TurningPoint by visiting and select Register for Access. You’ll fill out a validation form and submit it to TurningPoint. Once TurningPoint sets up your account, you can access the TurningPoint Provider Portal through

If you prefer to access the Provider Portal through your home plan’s website, log in to your home plan’s website and select an ID card prefix from Michigan. This will take you to the Blue Cross Blue Shield of Michigan website where you can select the Musculoskeletal service authorization through TurningPoint link and enter your NPI.

Preauthorization for the AIM Radiology Management Program

AIM Specialty Health pre-authorizes high technology services (PDF) for BCBSM's Medicare Advantage PPO radiology management program. Read this FAQ document (PDF) for information on changes to the 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 preauthorization.