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.

Preauthorization

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. 

Precertification

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 MedicarePlusBlueFacilityFax@bcbsm.com. 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. 

Prior authorizations for other services:

  • Musculoskeletal surgical procedures
  • Musculoskeletal pain management procedures
  • Physical therapy
  • Occupational therapy
  • Radiation therapy services
  • Spinal surgical procedures

eviCore

  • Lumbar spinal fusion surgery and interventional pain management services – effective Sept. 1, 2016 through Dec. 31, 2020
    Note: TurningPoint will manage prior authorizations for lumbar spinal fusion surgery and pain management services effective Jan. 1, 2021.
  • Physical therapy and occupational therapy – effective Jan. 1, 2017
    Note: Skilled nursing facilities providing physical and occupational therapy don't need to obtain prior authorization.
  • Radiation therapy services - effective Nov. 1, 2016

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.  

TurningPoint

TurningPoint Healthcare Solutions LLC manages inpatient and outpatient authorizations for the following services for Medicare Plus Blue members:

  • Musculoskeletal joint procedures – effective July 1, 2020
  • Musculoskeletal pain management procedures – effective Jan. 1, 2021
  • Musculoskeletal spinal surgical procedures – effective Jan. 1, 2021

Note: eviCore will continue to manage pain management and lumbar spinal fusion surgeries for Medicare Plus Blue members throughout 2020. For procedures with dates of service prior to Jan. 1, 2021, you can submit retroactive authorization requests to eviCore through April 30, 2021. Refer to our guidelines (PDF) for authorizations managed by eviCore.

Providers can submit prior authorization requests to TurningPoint through one of the following routes:

  • The TurningPoint provider portal which can be accessed through:
    • Provider Secured Services by logging in to bcbsm.com/providers.
      Note: If you’re having trouble accessing the TurningPoint provider portal using this process, contact the Blue Cross Web Support Help Desk at 1-877-258-3932.
    • The TurningPoint website by visiting myturningpoint-healthcare.com where you can register for access and log in.
      Note: You must register with TurningPoint before you can log in through the TurningPoint website. If you’re having trouble accessing the TurningPoint provider portal using this process, contact the TurningPoint Technical Support team at 313-908-6041. If you’re having trouble while working in the TurningPoint provider portal, contact TurningPoint Customer Service toll-free at 1-833-217-9670 or locally at 313-908-6040.
  • By calling TurningPoint at 1-833-217-9670.
  • By faxing the appropriate authorization request form to TurningPoint as follows:
    • Fax joint and spine procedures authorization request forms to 313-879-5509.
    • Fax pain management authorization request forms to 313-483-7323.

Refer to the Blue Cross Musculoskeletal services page for a list of the procedure codes that require authorization from TurningPoint and for more information on how to submit prior authorization requests.

When authorization is received, provide the appropriate facility with the authorization number.

Note for out-of-state providers: Log in to your local plan's website and select an ID card prefix from Michigan. This will take you to the Blue Cross Blue Shield of Michigan website. You can then click the Musculoskeletal Service Authorizations through TurningPoint link and enter your NPI. You may need to complete a one-time registration process with TurningPoint. After you register, you’ll have access to the Musculoskeletal service authorization through TurningPoint link in Provider Secured Services.

Prior authorization for advanced imaging, cardiology and in-lab sleep study services

AIM Specialty Health® manages authorizations for Medicare Plus Blue members for select outpatient advanced imaging, cardiology and in-lab sleep study services. This includes UAW Retiree Medical Benefits Trust members with Medicare Plus Blue coverage. It also includes cardiac implantable devices and services for dates of service on and after Jan. 1, 2021.

Without prior authorization, claims are denied and providers won't bill the member. Hospital inpatient care, emergency room care and urgent care don't require prior authorization.

Providers should submit prior authorization requests using the AIM Provider PortalSM. Providers can also call the AIM Contact Center at 1-800-728-8008. This FAQ page provides helpful information regarding AIM’s portal. We encourage providers to use the portal before scheduling prior authorization services.

Procedure codes and other information about outpatient advanced imaging, cardiology and in-lab sleep study services that require prior authorization by AIM are found on the Blue Cross AIM-Managed Procedures page.

Note: These authorization requirements apply only to Medicare Plus Blue 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.