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 how providers should submit requests; applies to Michigan and non-Michigan providers and various product lines.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPrior authorization requirements for Michigan and non-Michigan providers

Policy CodePolicy N/A

Change TypeAdministrative revision

Effective DateRevised June 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via Availity e-referral with the appropriate Blue Cross assessment form and complete clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Revised June 2026document revision date

24/7e-referral availability

72 hrsif no response

Jan 5, 2026WellSky management start

Mar 1, 2026tango start date

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.

Coverage & Authorization Criteria

Authorization criteria summary

Summary of coverage and authorization requirements by product line and service type.

ALL of the following

ABA (applied behavior analysis)
Requires prior authorization for select groups; speech/OT/PT do not require authorization
All inpatient partial and residential mental health and substance abuse facilities
Required to notify Blue Cross Behavioral Health for all admissions and discharges; most admissions require clinical review

ALL of the following

Organ transplants listed (bone marrow; heart; heart–lung; kidney (fully insured only); kidney–liver; liver; lobar lung; lung; multivisceral; pancreas; pancreas–kidney; partial liver; small bowel)
Providers must contact Blue Cross Human Organ Transplant department for prior authorization

ALL of the following

Acute care inpatient hospital medical and surgical admissions (including admissions for transplants and sick newborns)
Admissions to skilled nursing facilities, acute inpatient rehabilitation, and long-term acute care facilities
Maternity admissions
Generally do not require authorization though complicated admissions may require authorization

ALL of the following

Outpatient repetitive transcranial magnetic stimulation (rTMS)
Requires prior authorization for Blue Cross commercial members; coverage limited to select groups per medical policy

ALL of the following

Outpatient services not listed above
Medicare primary contracts
Coordination of benefits contracts

ALL of the following

Verify member eligibility prior to requesting authorization; claims will not be paid unless authorization is obtained
Use Availity e-referral to submit requests; during temporary outages fax submission is allowed per form instructions

ALL of the following

Authorization approval does not guarantee payment

General prior authorization criteria and processing

Authorization requests must include completed Blue Cross assessment forms and full clinical documentation to support medical necessity; incomplete requests may delay processing or be at risk of denial.

ALL of the following

Completed appropriate Blue Cross assessment form
Complete clinical documentation to support necessity of inpatient stay or transplant
Legible and fully completed forms or the request will not be processed

ALL of the following

Primary method: Availity e-referral (available 24/7)

Pharmacy prior authorization and step therapy

Some medications require prior authorization or step therapy; drug-specific clinical criteria and forms are available on the Medical Policies and Drug Lists pages; pharmacy prior authorizations may be submitted via ePA.

ALL of the following

Drugs listed on the formulary are covered when medically necessary and filled at a network retail or mail-order pharmacy
All plan rules apply such as prior authorization, step therapy and quantity limits

ALL of the following

Some medications administered by healthcare professionals require prior authorization and certain clinical criteria must be met before administration
Other drugs are subject to step therapy: patient must have trialed specified formulary agents before coverage

Appeals and retroactive reviews

Appeals and retroactive review windows: Blue Cross commercial retroactive reviews accepted for acute/post-acute care (2 years); appeals for prior authorization denials accepted up to 45 days.

ALL of the following

Blue Cross commercial will accept requests for retroactive reviews for acute care and post-acute care for up to 2 years after the date of service

ALL of the following

Retroactive authorization requests for post-acute acute care stays are accepted up to one year post-discharge (per post-acute retroactive guidance)

ALL of the following

Appeal requests must be submitted in writing within 45 days of the initial denial decision and include additional information to substantiate the need for the inpatient stay

Coverage with prior authorization requirements

Coverage is conditional on medical necessity and meeting prior authorization and network requirements as specified by managing vendors and plan type.

ALL of the following

Carelon: certain procedure codes for Michigan providers require prior authorization from Carelon Medical Benefits Management; refer to published procedure code lists
EviCore: manages prior authorizations for some outpatient radiation/oncology services for some Michigan members
TurningPoint: manages inpatient and outpatient authorizations for some musculoskeletal and pain management procedures for specified groups
Northwood: manages prior authorizations and supplier network for DME/P&O (including diabetes supplies) for Michigan providers and Medicare Plus Blue members

Administrative coverage notes

Coverage administration notes and exceptions for DME/P&O:

ALL of the following

Northwood, Inc. manages prior authorizations and the supplier network for DME/P&O and is the preferred provider for Michigan BlueCross commercial fully insured groups, individual members, and Medicare Plus Blue members
Non-Michigan providers must use a DME supplier that participates as a Traditional provider with the member's local Blue Cross plan

ALL of the following

Exception: For continuous glucose monitor (CGM) products see the CGM section; for dates of service on or after Oct. 1, 2024 Medicare Plus Blue members must obtain CGMs through a participating network pharmacy; exceptions apply for UAW Retiree Medical Benefits Trust members

ALL of the following

Codes & Billing Guidance

Reference to code lookup job aidmixed

Procedure and service codes determining prior authorization requirements are identified via the Determining prior authorization requirements for members job aid on authorizations.bcbsm.com (Determine Prior Authorization Requirements for Members tile).

Procedure codes requiring Carelon prior auth (Michigan)mixedCovered

Procedure code lists referenced for Carelon-managed prior authorization (links provided in source: Procedure codes for which providers must request prior authorization; Radiation Oncology Prior Authorization List for UAW Retiree Medical Benefits Trust nonMedicare members).

Procedure codes requiring prior authorizationmixed

Procedure codes requiring prior authorization are listed in the referenced 'Procedure codes for which providers must request prior authorization' document and related webpages (Cardiology, Oncology, Radiology Services).

Private duty nursing billing codesCPTCovered

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 pointing to medical policy

Coverage statusOutpatient repetitive transcranial magnetic stimulation (rTMS) requires prior authorization and is limited to select groups meeting strict selection criteria per the Blue Cross medical policy on Transcranial magnetic stimulation.

Applies toBlue Cross commercial members (rTMS applies only to commercial members).

Where to find criteriaSelection criteria and coverage details available in the Blue Cross medical policy on Transcranial magnetic stimulation (Medical Policy Router Search at bcbsm.com).

Retroactive authorization window (post-acute) — 1 year post-discharge note

Retroactive authorization windowRetroactive authorization requests for post-acute acute care stays will be accepted up to one year post-discharge.

Submission Methods & Provider Responsibilities

Prior Authorization

General prior authorization requirement

Providers must submit prior authorization (PA) requests before providing services. Michigan law requires electronic submission for commercial members via Availity e-referral; alternate methods (phone, fax, mail) are allowed only for temporary technological outages (power/internet). Include complete clinical documentation with all requests; incomplete submissions may delay processing or result in denial.

Use Availity e-referral for commercial members in Michigan whenever possible
If e-referral unavailable, follow alternate submission methods below

Prior Authorization

Behavioral health prior authorization submission

Prior authorization for outpatient and inpatient behavioral health services can be submitted electronically through Availity: log in at availity.com, select Payer Spaces > BCBSM and BCN logo, then the Blue Cross Behavioral Health tile. Phone submission and additional guidance are available via the Blue Cross Behavioral Health: Frequently asked questions for providers document.

Electronic submission: Availity provider portal > Payer Spaces > BCBSM and BCN > Blue Cross Behavioral Health tile

Terms & Definitions

Prior authorization definition — definition of prior authorization for Blue Cross

DefinitionPrior authorization is a process where Blue Cross Blue Shield of Michigan requires providers to obtain approval before providing certain procedures or services to ensure appropriate care, location, and timing.

Provider responsibilityHealth care providers must submit prior authorization requests before providing services and, for some services, include clinical documentation demonstrating medical necessity.

Electronic submission requirementMichigan law requires electronic submission of prior authorization requests for commercial members; alternate methods allowed during temporary technology outages.

e-referral / EPA definition — electronic submission system via Availity

Definitione-referral (EPA) is an electronic system providers use to submit prior authorization requests; Availity e-referral is available 24/7 for Blue Cross submissions.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPrior authorization requirements for Michigan and non-Michigan providers

Policy CodePolicy N/A

Change TypeAdministrative revision

Effective DateRevised June 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests via Availity e-referral with the appropriate Blue Cross assessment form and complete clinical documentation.

SourceLink

On This Page

If experiencing temporary technological outages, submit via fax using the appropriate assessment form per instructions

Acute inpatient requests for Michigan must be submitted within 24 to 72 hours of the admission (per facility guidance)

ALL of the following

Incomplete requests may delay processing; Blue Cross may attempt to obtain additional information but will process with available information if not received timely
Requests are processed during regular business hours (8 a.m.–5 p.m. EST, Monday–Friday); non-urgent requests received after hours processed next business day
InterQual criteria are used for acute hospital, SNF, inpatient rehab, and LTACH prior authorization and recertification

ALL of the following

If no response within 72 hours, call 1-800-249-5103 and follow prompts to reach Commercial Precertification

ALL of the following

Non-Michigan providers should submit via their local Blue plan's EPA portal; if unavailable, fax completed acute inpatient assessment form and documentation

ALL of the following

FEP requests may have additional requirements—contact FEP benefits at 1-800-482-3600

ALL of the following

If additional information is not received in a timely manner, Blue Cross will process the request in accordance with legislative and accreditation time frames

Prior authorization and step therapy requirements differ based on the member's formulary

ALL of the following

Refer to Medical Policies and Drug Lists pages for clinical criteria and forms
Prescribing physician should complete the online PA form and submit via electronic prior authorization (ePA) tool; alternate fax submission options available
For Medicare members, view Drug Lists for Medicare Members and submit via the Blue Cross Pharmacy Benefit Drugs page

ALL of the following

If needed, pharmacy prior authorizations may be submitted via fax to 1-866-601-4425 or by mail to Pharmacy Services P.O. Box

ALL of the following

Specific drug-level criteria and step therapy rules are documented on the plan's drug list and medical policy pages; consult those resources for member-specific requirements

Fax appeal and supporting documents to 1-877-261-4555

ALL of the following

Providers may request peer-to-peer reviews for inpatient medical necessity denials using the process described in Blue Cross documentation

Tango/WellSky/Alacura: Home health (tango) and post-acute (WellSky as of Jan 5, 2026) and non-emergency air ambulance (Alacura) have vendor-managed authorizations

ALL of the following

Certain services (select advanced imaging, outpatient cardiology, CRT, ICD, arterial ultrasound) require prior authorization for Medicare Plus Blue members
For 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

ALL of the following

Non-Michigan providers: prior authorization is not required generally except for specific member groups (e.g., URMBT); non-Michigan providers should use their local Blue plan's EPA portal or follow fax procedures

ALL of the following

Coverage is conditional on medical necessity and meeting the applicable prior authorization and network requirements specified by the member's plan and any managing third-party vendor

Refer providers to the Durable medical equipment, prosthetics, orthotics and medical supplies management program FAQ for program details and supplier requirements

ScopeApplies to post-acute acute care stays referenced in the post-acute care section.

ReferenceSee 'Retroactive reviews' section for details on submission timing and requirements.

Private duty nursing unit definition — 1 unit = 1 hour

Unit definitionOne unit equals one hour; agencies should indicate total hours as units when billing private duty nursing services.

Billing codesUse S9123 for RN and S9124 for LPN when submitting authorization requests and billing.

Authorization requirementPrivate duty nursing services require prior authorization for dates of service on or after Oct. 1, 2022; submit requests through the e-referral system.

Phone submission: see Behavioral Health FAQ on authorizations.bcbsm.com

Prior Authorization

Organ transplant prior authorization and alternate submission

Human organ transplant prior authorization requests must be directed to Blue Cross' Human Organ Transplant department. If you cannot access the e-referral system due to temporary technology problems, call to submit the request.

Transplants requiring PA include bone marrow, heart, heart-lung, kidney (fully insured only), kidney-liver, liver, lobar lung, lung, multivisceral, pancreas, pancreas-kidney, partial liver, small bowel
Alternate submission when e-referral is unavailable: call Human Organ Transplant department at 1-800-242-3504 (8 a.m.–5 p.m. EST, Mon–Fri)

Prior Authorization

Acute and post-acute authorization submission via Availity e-referral

Acute inpatient and post-acute authorization requests must be submitted via the Availity e-referral system 24/7 using the appropriate Blue Cross assessment form and full clinical documentation. Include the completed assessment form with supporting records; incomplete requests may delay processing.

Submit request on the appropriate Blue Cross assessment form via Availity e-referral
Attach complete clinical documentation to support medical necessity
Availity e-referral is available 24/7 through the provider portal

Prior Authorization

Fax submission alternative and required forms

If you cannot use the e-referral system because of temporary technical problems, you may submit acute and post-acute prior authorization requests by fax using the appropriate Blue Cross assessment form. The form and clinical documentation must be provided together and be fully completed and legible or the request will not be processed.

Acute inpatient hospital assessment form: https://www.bcbsm.com/amslibs/content/dam/public/providers/documents/forms/acute-inpatient-fax-assessment-form.pdf
SNF/acute IPR assessment form: https://www.bcbsm.com/amslibs/content/dam/public/providers/documents/forms/bcbsm-bcn-comm-snf-ipr-assessment-form.pdf
LTACH assessment form: https://www.bcbsm.com/amslibs/content/dam/public/providers/documents/forms/bcbsm-bcn-comm-ltach-assessment-form.pdf
Fax submissions must include the completed assessment form and supporting clinical documentation together

Note

Authorization status inquiry

If you have not received a response within 72 hours for a prior authorization request, call the Blue Cross Commercial Precertification line during regular business hours and follow prompts to obtain status information.

Call 1-800-249-5103 and follow prompts: select 'Precertification' and provide facility code or 10-digit NPI, member ID/policy number, member DOB, first five letters of member's first name, and type of service
You will be transferred to a Commercial Precertification representative if needed

Prior Authorization

Pharmacy prior authorization guidance

Pharmacy prior authorizations are required when plan rules (formularies, step therapy, quantity limits) indicate; drugs are generally covered when medically necessary and filled at a network retail or mail-order pharmacy. Submit pharmacy PA requests per Blue Cross Pharmacy Services processes; alternate fax/mail submission is available for pharmacy PAs during e-referral outages.

Formulary drugs covered if medically necessary and filled at a network pharmacy; follow plan PA, step therapy, and quantity-limit rules
View drug lists and criteria at bcbsm.com/providers (Drug Lists for Medicare Members and Pharmacy Benefit Drugs pages)
Alternate submission for pharmacy PAs (if e-referral unavailable): fax 1-866-601-4425 or mail to Blue Cross Blue Shield of Michigan Pharmacy Services, P.O. Box 312320, Detroit, MI 48231-2320

Prior Authorization

Sleep studies and hypoglossal device prior authorization

In‑lab sleep studies and implantation of hypoglossal nerve stimulation devices require prior authorization per group-specific rules and dates of service. Carelon manages PAs for certain employer groups and dates of service; Blue Cross Utilization Management manages others. Check the procedure-code list and Carelon exclusion list to determine who manages the PA.

For dates of service on/after Nov. 3, 2025: select employer groups (Chrysler, Delphi/Aptiv, GM, UAW Retiree) require Carelon PA for adults; many fully insured and individual groups require Blue Cross UM PA
For dates before Nov. 3, 2025: Carelon managed PAs for Michigan providers per the procedure-code list
Refer to 'Procedure codes for which providers must request prior authorization' and Carelon FAQ and sleep studies FAQ documents on authorizations.bcbsm.com

Prior Authorization

Private duty nursing prior authorization and billing

Private duty nursing services require prior authorization for dates of service on or after Oct. 1, 2022. Submit PA requests through Availity e-referral. For authorization and billing, agencies must use S9123 for RN or S9124 for LPN and report total hours as units (1 unit = 1 hour).

Submit private duty nursing PA requests via e-referral
Billing codes: S9123 = RN, S9124 = LPN; enter total hours as units (1 unit = 1 hour)
See the Private duty nursing program document on authorizations.bcbsm.com for complete instructions

Prior Authorization

Home health prior authorization via tango

Home health prior authorization for Medicare Plus Blue episodes of care starting on or after March 1, 2026 is managed by tango. Episodes that start before March 1 and continue through or beyond March 1 also require tango authorization. Episodes that start and end before March 1, 2026 do not require prior authorization.

For episodes starting on/after Mar. 1, 2026: obtain prior authorization through tango
For episodes starting before Mar. 1 but continuing through/beyond Mar. 1, 2026: obtain prior authorization through tango
For episodes starting and ending before Mar. 1, 2026: prior authorization not required
Refer to Home Health Care Resources and procedure-code list on authorizations.bcbsm.com

Prior Authorization

EviCore oncology prior authorization

EviCore may require prior authorization for certain outpatient radiation/oncology services for Michigan-resident members receiving care from Michigan providers. Determine whether EviCore authorization is required using Blue Cross tools, and submit requests through the EviCore provider portal or Availity EviCore tile. Phone submission to EviCore is also available.

To determine EviCore requirements, follow the 'Determine prior authorization requirements for members' document
Submit PAs via EviCore portal (eviCore.com/provider) or Availity > Payer Spaces > BCBSM and BCN > EviCore Provider Portal tile
Alternate phone submission: call EviCore at 1-877-917-2583

Prior Authorization

TurningPoint musculoskeletal and pain management prior authorization

TurningPoint Healthcare Solutions manages prior authorizations for many musculoskeletal surgical procedures and pain management procedures for specified groups and dates. Verify whether TurningPoint manages the member's PA and follow TurningPoint submission instructions; some groups and FEP members have different management or date-based rules.

TurningPoint manages musculoskeletal surgical and pain management PAs for most fully insured Blue Cross commercial groups, select self-funded groups, individual members, and Medicare Plus Blue where applicable
For Blue Cross and Blue Shield Federal Employee Program commercial members, Blue Cross manages certain musculoskeletal PAs effective Jan. 1, 2026
To determine required procedure codes, see 'Procedure codes for which providers must request prior authorization'
For submission details, see TurningPoint 'How do I submit authorization requests' section on authorizations.bcbsm.com

EPA for non-Michigan providersElectronic Provider Access (EPA) allows providers outside Michigan who are not registered with Availity Essentials to submit requests via their local Blue plan portal.

Alternate methodsAlternate submission methods (fax/phone) are allowed during temporary technological outages; specific forms apply for different request types.

Precertification — definition reference for precertification

DefinitionPrecertification refers to the process of obtaining authorization for services; providers may follow prompts via the Precertification option when calling 1-800-249-5103 to check status or request assistance.

Use of criteriaInterQual criteria are used to complete acute hospital, skilled nursing, inpatient rehabilitation and long-term acute care precertification and recertification requests.

Processing hoursRequests processed during regular business hours, 8 a.m. to 5 p.m. EST, Monday through Friday and select holidays; non-urgent requests after hours processed next business day.

WellSky — third-party manager definition for post-acute prior authorizations effective Jan 5, 2026

DefinitionWellSky is an independent company that will manage post-acute care prior authorizations for stays that start on or after Jan. 5, 2026.

Transition timingFor stays that start on or before Jan. 4, 2026, prior authorizations are managed by Blue Cross Blue Shield of Michigan; refer to the post-acute care FAQ for details.

Reference documentSee 'Post-acute care services for Medicare Advantage members: Frequently asked questions for providers' for submission and management details.

Formulary drugs — definition of drugs subject to medical necessity and plan rules

DefinitionFormulary drugs are medications listed in the plan formulary that are covered when medically necessary, filled at a network pharmacy, and when all plan rules (prior authorization, step therapy, quantity limits) are followed.

Where to find listsFormulary and drug list documents are available on the Drug Lists for Medicare Members page at bcbsm.com/providers.

PA submission infoFor clinical criteria or to submit a pharmacy prior authorization, refer to the Blue Cross Pharmacy Benefit Drugs page at ereferrals.bcbsm.com.

Episode of care — definition used to determine tango prior authorization applicability

DefinitionAn episode of care is a period of home health care beginning on a start date; whether an episode requires prior authorization through tango depends on the episode start date.

Tango applicabilityEpisodes that start on or after March 1, 2026 (or start before and continue through/after that date) require prior authorization through tango; episodes starting and ending before March 1, 2026 do not require prior authorization.

ReferenceSee Home Health Care Resources on authorizations.bcbsm.com for provider requirements and referral information.

CGM exception — note about continuous glucose monitor products handled separately

CGM exceptionContinuous glucose monitor (CGM) products are addressed in a separate 'Continuous glucose monitor products' section and have specific requirements (e.g., Medicare Plus Blue members must obtain CGMs through network pharmacy for dates of service on/after Oct. 1, 2024).

DME/P&O relationshipCGM products are considered within the DME/P&O section exception and managed via Northwood, Inc. for Michigan providers regarding prior authorizations and supplier network.

Reference noteRefer to the 'Continuous glucose monitor products' section in this document for details and exceptions (including UAW Retiree exception).

Third-party prior authorization managers — definition of independent companies contracted to manage PAs

DefinitionThird-party prior authorization managers are independent companies contracted by Blue Cross Blue Shield of Michigan and Blue Care Network to manage or review prior authorizations for select services.

Named companiesNamed managers include Carelon Medical Benefits Management, EviCore by Evernorth, Northwood Inc., Tango, WellSky, Alacura, and TurningPoint Healthcare Solutions LLC.

RoleThese companies manage prior authorizations, review medical necessity, coordinate networks, and process claims for specified service categories on behalf of Blue Cross.