CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Prior authorization requirements for Michigan and non-Michigan providers

Governs which procedures and services require prior authorization for Blue Cross commercial and Medicare Plus Blue members and explains submission channels and responsible review entities. Affects providers submitting authorization requests for these members.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPrior authorization requirements for Michigan and non-Michigan providers

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateRevised April 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests electronically using the e-referral system or EPA; use alternate methods only for temporary outages.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Apr 2026Document revision

24/7e-referral availability

Up to 2 yearsRetro review window (commercial acute/post-acute)

45 daysAppeal window

Jan 5, 2026Post-acute management transition

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

NorthwoodPreferred DME manager (MI)

Services and Coverage Rules Requiring Prior Authorization

CGM and DME prior authorization and supplier criteria

Continuous glucose monitor (CGM) products and durable medical equipment (DME) supplier rules — prior authorization and supplier channel requirements for Blue Cross commercial and Medicare Plus Blue members.

Blue Cross commercial products (non-Medicare) — Michigan providers: Northwood, Inc. manages prior authorizations and the supplier network for CGM products and is the preferred supplier for fully insured groups and individual members who reside in Michigan. Providers should refer to the Durable medical equipment, prosthetics, orthotics and medical supplies management program: Frequently asked questions for providers for details on authorization submission, supplier enrollment, and claim routing.

Non-Michigan providers: For members with addresses outside of Michigan, non-Michigan providers must use a DME provider that participates as a Traditional provider with the member's local Blue Cross plan. Verify local network participation before ordering or dispensing CGM devices.

Commercial members with pharmacy benefit coverage: Commercial members who have pharmacy benefits through Blue Cross may obtain CGM products through a participating network pharmacy. Prior authorization may be required in certain circumstances; check the Continuous glucose monitor products: FAQs for providers document for specifics on when pharmacy-channel dispensing applies and any prior authorization rules.

Medicare Plus Blue members (dates of service on or after Oct. 1, 2024): Medicare Plus Blue members must obtain CGM products through a participating network pharmacy. Prior authorization may be required in certain circumstances. Exception: UAW Retiree Medical Benefits Trust members with Medicare Plus Blue plans should continue to obtain CGM products through a DME supplier.

Operational notes: Confirm member-specific benefit design and channel (pharmacy vs DME) before initiating prior authorization or ordering CGM supplies. Prior authorization rules and the preferred supplier network may vary by group (fully insured, self-funded, UAW Retiree Medical Benefits Trust) and by member residence (Michigan vs non-Michigan). Refer to the referenced FAQs and the DME management program documentation for submission instructions, required documentation, and supplier contact information.

Procedure Codes and Coding Notes

Procedure code determinationmixed

No codes listed

Carelon-managed procedure code lists (Michigan)mixedCovered

Procedure codes requiring prior authorization are listed on payer-maintained lists (links provided) including: 'Procedure codes for which providers must request prior authorization' and 'Radiation Oncology Prior Authorization List for UAW Retiree Medical Benefits Trust nonMedicare members'.

Private duty nursing HCPCS codesHCPCSCovered

S9123	Private duty nursing - RN (enter total hours as units)
S9124	Private duty nursing - LPN (enter total hours as units)

rTMS coverage — limited coverage note for rTMS per medical policy

Coverage statusPrior authorization required for outpatient repetitive transcranial magnetic stimulation (rTMS); coverage limited to select groups meeting strict selection criteria per the Blue Cross medical policy on Transcranial Magnetic Stimulation.

Applicable membersBlue Cross commercial products (non-Medicare) and Medicare Plus Blue where specified; outpatient rTMS applies only to Blue Cross commercial members.

Policy referenceSelection criteria available in the Blue Cross medical policy on Transcranial Magnetic Stimulation (Medical Policy Router Search at bcbsm.com).

Step therapy — step therapy requirements for some drugs

RequirementSome drugs are subject to step therapy; the patient must have been treated with one or more formulary agents before certain non-formulary drugs are covered.

Submission Methods, Operational Steps, and Vendor Routes

Prior Authorization

Inpatient/Post‑Acute Authorization Submission

Prior authorization requests for inpatient admissions, transfers, transplant procedures and post-acute care for Michigan facilities (and other facilities with Availity access) must be submitted through the Blue Cross e-referral system on Availity.com. Requests must use the appropriate Blue Cross assessment form and include complete clinical documentation to support the medical necessity of the inpatient stay, transplant or post-acute placement. Incomplete or illegible forms and missing documentation may delay processing; Blue Cross may attempt to request additional information, but if not received in a timely manner the request will be processed with the information available per legislative and accreditation time frames. If you cannot access e-referral due to temporary technology issues (for example power or internet outage), fax submission is allowed using the assessment form instructions. For information and forms, see authorizations.bcbsm.com.

Submit inpatient/transplant requests on the appropriate Blue Cross assessment form with supporting clinical documentation.
If additional information is requested but not received timely, Blue Cross will process with available information per required timeframes.
If e-referral is unavailable due to temporary technical problems, submit via fax per the assessment form instructions.

Key Terms and Program Definitions

Prior authorization definition — definition and purpose

DefinitionPrior authorization is a requirement that providers submit a request (usually with clinical documentation) before providing certain services to ensure the care is appropriate in timing and location.

PurposeTo ensure members get the right care at the right time and in the right location and to support medical necessity reviews.

Provider actionProviders must submit prior authorization requests and include clinical documentation when required; authorization approval does not guarantee payment.

e-referral definition — electronic referral system definition

Definitione-referral is an electronic system that providers can use to submit prior authorization requests via the Availity provider portal.

Availability

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPrior authorization requirements for Michigan and non-Michigan providers

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective DateRevised April 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests electronically using the e-referral system or EPA; use alternate methods only for temporary outages.

SourceLink

On This Page

VariationStep therapy and prior authorization requirements differ based on the member's formulary and drug list.

How to verifySee the Prior Authorization and Step Therapy Guidelines for the member's specific drug list on the For Providers: Drug Lists page at bcbsm.com/providers.

Note

Alternate Transplant Submission Method

If temporary technological problems prevent access to the e-referral system for human organ transplant authorization requests, call the Blue Cross Human Organ Transplant department to obtain prior authorization. This is an alternate submission route only for eligible temporary outages.

Call 1-800-242-3504 for Human Organ Transplant prior authorization.
Hours: 8 a.m. to 5 p.m. EST, Monday through Friday.

Documentation Required

Submission Methods and Required Documentation

When submitting inpatient, transplant or post-acute prior authorization requests, include the fully completed Blue Cross assessment form AND all required clinical documentation together. Requests submitted without the completed form or supporting documentation will not be processed until complete and may be delayed or denied.

Completed Blue Cross assessment form must accompany supporting clinical documentation.
Legible, fully completed forms reduce processing delays and risk of denial.

Note

Status and Processing Times

If you have not received a response within 72 hours for non-urgent inpatient/post-acute requests, call the status line during regular business hours. Requests are processed during regular business hours (8 a.m. to 5 p.m. EST, Monday–Friday) and any non-urgent requests received after hours or on weekends/holidays will be handled the next business day.

Status inquiries: Call 1-800-249-5103 and follow prompts (Precertification) — have facility code or 10-digit NPI, member ID/policy number, DOB, first five letters of member's first name and type of service ready.
Processing hours: 8 a.m. to 5 p.m. EST, Monday through Friday; after-hours requests processed next business day.
If no response within 72 hours, use the status inquiry process above.

Prior Authorization

Carelon Prior Authorization for Certain Procedure Codes

Certain procedure codes require prior authorization through Carelon Medical Benefits Management for Michigan providers under Blue Cross commercial products (non-Medicare). Confirm whether the member and procedure are subject to Carelon requirements and follow Carelon submission instructions where applicable.

Review 'Procedure codes for which providers must request prior authorization' to see codes managed by Carelon.
In‑lab sleep and hypoglossal nerve stimulation device implantations (for specified groups) may require Carelon authorization for DOS on/after Nov. 3, 2025 — check the Carelon exclusion list for specifics.
Non‑Michigan provider requirements and exclusions are documented in the Carelon exclusion list.

Prior Authorization

Non‑Emergency Air Ambulance Prior Authorization

All non‑emergency air ambulance (fixed‑wing and rotor) flights require prior authorization from Alacura Medical Transport Management; obtain authorization before the flight.

Non‑emergency air ambulance must be authorized by Alacura before transport.
Refer to the 'Non-emergency air ambulance prior authorization program: Overview for Michigan and non-Michigan providers' for submission instructions.

Prior Authorization

Home Health Prior Authorization via tango

For Medicare Plus Blue home health episodes of care starting on or after March 1, 2026, prior authorization is required through tango, which manages the home health network, referrals, authorizations and claim processing. Episodes that start and end before March 1, 2026 do not require prior authorization.

For episodes starting on/after March 1, 2026 (and episodes that begin before but continue through/beyond March 1), submit prior authorization requests via tango per the Home Health Care Resources guidance.
Refer to 'Procedure codes for which providers must request prior authorization' to confirm affected codes.

Note

TurningPoint Access for Non‑Michigan Providers

Non‑Michigan providers have multiple methods to access the TurningPoint portal and should follow the TurningPoint access guidance for submitting musculoskeletal prior authorization requests. If e-referral is unavailable, TurningPoint provides fax and phone alternatives.

See the TurningPoint 'How do I submit authorization requests?' FAQ for portal access options for non‑Michigan providers.
Alternate submission to TurningPoint when portal inaccessible: fax joint and spine forms to 313-879-5509, pain management forms to 1-313-483-7323, or call 1-833-217-9670 / 1-313-908-6040 (available 8 a.m.–8 p.m. EST weekdays).
Retroactive requests to TurningPoint may be submitted up to 90 days after the procedure.

Note

Northwood, Inc. Manages DME/CGM Prior Authorizations (Michigan)

For Blue Cross commercial and Medicare Plus Blue members who reside in Michigan, Northwood, Inc. manages prior authorizations and the supplier network for continuous glucose monitor (CGM) products and for DME/P&O (preferred provider) for specified groups and members. Non‑Michigan providers must use a DME supplier that participates as a Traditional provider with their local Blue plan.

Michigan providers: Northwood, Inc. is the manager for CGM prior authorizations and preferred DME/P&O supplier network for fully insured commercial groups, individual members and Medicare Plus Blue members.
Non‑Michigan providers: Use a DME supplier that participates as a Traditional provider with your local Blue Cross plan for members with addresses outside Michigan.
Commercial members with pharmacy benefits may obtain CGM products through participating network pharmacies; prior authorization may be required in some circumstances.

The Blue Cross e-referral system is available 24 hours per day, 7 days a week to receive inpatient admission and transplant authorization requests.

Alternate methodIf e-referral is unavailable due to temporary technological problems, prior authorization requests may be submitted via fax using the appropriate Blue Cross assessment form.

Electronic Provider Access (EPA) — definition and use for non-Michigan providers

DefinitionElectronic Provider Access (EPA) is a platform that providers outside Michigan and not registered with Availity Essentials can use to submit prior authorization requests via their local Blue plan portal.

Use caseNon-Michigan providers may use their home plan's EPA portal to look up requirements and submit prior authorization requests without an Availity account.

Access noteEPA is accessed through the provider's local Blue plan portal and is intended for providers not registered with Availity Essentials.

Non-urgent request — definition and classification

DefinitionNon-urgent request: a prior authorization request received after regular business hours or on a weekend/holiday that will be processed the next business day.

ProcessingRequests are processed during regular business hours (8 a.m. to 5 p.m. EST, Mon–Fri); non-urgent requests received after hours are processed the following business day.

Status follow-upIf no response within 72 hours, providers can call 1-800-249-5103 during regular business hours to obtain request status.

Assessment form required for prior authorization submissions — Blue Cross assessment form requirement

RequirementAuthorization requests must be submitted on the appropriate Blue Cross assessment form along with complete clinical documentation to support the request; incomplete forms will not be processed.

When fax allowedIf the e-referral system is unavailable due to temporary technological problems (e.g., power or internet outage), prior authorization requests can be submitted via fax using the appropriate Blue Cross assessment form.

Where to find formsAssessment forms and submission instructions are available on authorizations.bcbsm.com and via specific links provided for each form type.

Episode of care — episode start date definition

DefinitionEpisode of care start date: the date an episode of home health care begins; episodes starting on or after March 1, 2026 require prior authorization through tango.

Authorization triggerFor episodes that start on or after March 1, 2026, prior authorization must be obtained via tango; episodes that start and end before March 1, 2026 do not require authorization.

ScopeApplies to Medicare Plus Blue members for home health care episodes and the tango-managed network and processes.

In-lab sleep study — definition used for prior authorization rules

DefinitionIn-lab sleep study: polysomnography performed in a sleep laboratory; for certain employer groups and dates of service on or after Nov. 3, 2025, prior authorization is required from Carelon for indicated procedure codes.

Authorization detailFor adult members covered through Chrysler, Delphi/Aptiv, General Motors or UAW Retiree Medical Benefits Trust, Carelon authorization is required for the specified procedure codes; other groups use Blue Cross Utilization Management.

ReferenceRefer to the Procedure codes for which providers must request prior authorization and Carelon exclusion list for determinations and exclusions.

EFT program — electronic funds transfer and online voucher program definition

DefinitionEFT program: an electronic funds transfer and online voucher program that sends payments electronically to financial accounts and lets providers view and print remittance advices online.

BenefitEnables providers to receive payments faster via electronic transfer and access remittance vouchers online.

How to enrollLearn more and sign up via the For Providers: What is the Electronic Funds Transfer and Online Voucher Program? page on bcbsm.com.

Northwood, Inc. — vendor definition and role managing DME/P&O and diabetes supplies

What Northwood doesNorthwood, Inc. manages prior authorizations and the supplier network for continuous glucose monitor (CGM) products and for durable medical equipment, prosthetics and orthotics (DME/P&O) and medical supplies for Michigan-based members.

Preferred providerNorthwood is the preferred supplier manager for fully insured groups, individual members and Medicare Plus Blue members who reside in Michigan.

Non-Michigan noteNon-Michigan providers must use a DME provider that participates as a Traditional provider with the member's local Blue Cross plan for members with addresses outside Michigan.