Currentblue cross blue shield - michiganPolicy N/A

BCBSM / BCN: Referral, Plan Notification, and Prior Authorization Requirements (Michigan)

Governs referral, plan notification, and prior authorization requirements for Blue Cross Blue Shield of Michigan and Blue Care Network members in Michigan; affects providers submitting referrals/authorizations and specifies which member types and regions the rules apply to.

Policy Summary

Payerblue cross blue shield - michigan

PolicyReferral, Plan Notification, and Prior Authorization Requirements (Michigan)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateRevised Feb 2026

Next Review DateN/A

Key ActionSubmit referral requests and plan notifications through the e-referral system for BCN East and Southeast regions; providers in other regions do not need to submit referrals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

BCN commercialReferral/plan notification applies

East/SoutheastRegional e-referral

MultipleServices with PA

MultipleDelegated vendors

MIApplies to

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Prior Authorization and Coverage Criteria

Prior authorization criteria summary

Summarized prior authorization stance by service area and product type.

ALL of the following

Blue Cross commercial fully insured: No
Blue Cross commercial self-funded: No
Medicare Plus Blue: No
BCN commercial: No
BCN Advantage: No

ALL of the following

Blue Cross commercial fully insured: Yes (Blue Cross Behavioral Health)
Blue Cross commercial self-funded: Yes if the group opts into the Blue Cross autism program (Blue Cross Behavioral Health)
Medicare Plus Blue: Yes (Blue Cross Behavioral Health)
BCN commercial: Yes (Blue Cross Behavioral Health)
BCN Advantage: Yes (Blue Cross Behavioral Health)

ALL of the following

Blue Cross commercial fully insured: Yes (Blue Cross Behavioral Health)
Blue Cross commercial self-funded: Yes if the group offers the TMS benefit (Blue Cross Behavioral Health)
Medicare Plus Blue: No
BCN commercial: Yes (Blue Cross Behavioral Health)
BCN Advantage: Yes (Blue Cross Behavioral Health)

ALL of the following

All listed products: Yes (Blue Cross Behavioral Health)

ALL of the following

Blue Cross commercial fully insured: Yes (Alacura Medical Transport Management, non-emergency flights only)
Blue Cross commercial self-funded: Yes (Alacura Medical Transport Management, non-emergency flights only)
Medicare Plus Blue: No
BCN commercial: Yes (Alacura Medical Transport Management, non-emergency flights only)
BCN Advantage: No

ALL of the following

Blue Cross commercial fully insured: Yes (Northwood, Inc. preferred)
Blue Cross commercial self-funded: No (may be managed by dispensing DME supplier)
Medicare Plus Blue: Yes (Northwood for dates of service on or after Oct. 1, 2024; prior to that Northwood preferred)
BCN commercial: Yes (Northwood, Inc.)
BCN Advantage: Yes (Northwood, Inc.)

Selected service prior authorization matrix examples

Examples extracted from the summary table (service -> prior auth required? -> decision maker / notes).

ALL of the following

Blue Cross commercial fully insured: Yes
Blue Cross commercial self-funded: Yes (except select groups)
Medicare Plus Blue: Yes
BCN commercial: Yes
BCN Advantage: Yes

Sample product-specific authorization rules

Examples of coverage/authorization requirements by product and service include:

ALL of the following

Blue Cross commercial fully insured: No prior auth
Blue Cross commercial self-funded: No prior auth
Medicare Plus Blue: No prior auth
BCN commercial: Yes - EviCore by Evernorth
BCN Advantage: Yes - EviCore by Evernorth

ALL of the following

Services and Codes Requiring Prior Authorization

Services that require prior authorization (summary)mixed

S9123	Private duty nursing, per hour
S9124	Private duty nursing, per hour (alternate)

Private Duty Nursing HCPCSHCPCSCovered

S9123	Private duty nursing, per hour
S9124	Private duty nursing, per hour

Other UM program notes (referenced)mixed

See Summary of utilization management programs for Michigan providers — prior authorization requirements vary by product (Blue Cross commercial fully insured, self-funded, BCN commercial, BCN Advantage, Medicare Plus Blue) and by vendor (Utilization Management department, EviCore, TurningPoint, WellSky, Human Organ Transplant team).

Not applicable / visit limits

Private duty nursing codes includedHCPCS S9123, S9124

Prior authorization requiredYes for select groups and members who have the benefit (verify via provider portal).

Referral, Notification, and Prior Authorization Workflow for Providers

Note

Use e-referral for BCN East/Southeast; not required Mid/West/UP

Submit referral requests and plan notifications to BCN through the e-referral system for BCN commercial members in the East and Southeast regions; referrals and plan notifications are not required in the Mid, West and Upper Peninsula regions.

Referral and plan notification requirements apply only to BCN commercial members.
When the group's medical care headquarters is in East or Southeast, use the e-referral system.
If the group's headquarters is in Mid, West or Upper Peninsula, providers do not need to submit referrals or plan notifications.

Prior Authorization

Provider responsibility to identify and obtain prior authorization

Providers are responsible for identifying when a prior authorization is needed via the provider portal (availity.com) or Provider Inquiry and must contact Blue Cross, BCN or the designated vendor to obtain authorization.

Check the provider portal (availity.com) or Provider Inquiry to determine PA requirements.

Vendor and Term Definitions

Plan notification — definition

TermPlan notification

DefinitionPlan notification alerts BCN to a scheduled service and facilitates claims payment (clinical review is not needed).

Submission methodSubmit plan notifications through the e-referral system where required (see regional rules).

Referral requirement scope

ScopeReferral requirements apply only to BCN commercial members; they do not apply to Blue Cross commercial, Medicare Plus Blue, or BCN Advantage members.

Regional variationRequirements vary by region and BCN product — providers must follow rules for the region where their medical care group's headquarters is located.

Policy Summary

Payerblue cross blue shield - michigan

PolicyReferral, Plan Notification, and Prior Authorization Requirements (Michigan)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateRevised Feb 2026

Next Review DateN/A

Key ActionSubmit referral requests and plan notifications through the e-referral system for BCN East and Southeast regions; providers in other regions do not need to submit referrals.

SourceLink

On This Page

Decision maker: Carelon Medical Benefits Management (where indicated)

ALL of the following

Blue Cross commercial fully insured: No
Blue Cross commercial self-funded: No
Medicare Plus Blue: No
BCN commercial: Yes
BCN Advantage: Yes
Decision maker: Joint Venture Hospital Laboratories for BCN plans

ALL of the following

Blue Cross commercial fully insured: No
Blue Cross commercial self-funded: No
Medicare Plus Blue: Yes (for episodes starting on/after March 1, 2026)
BCN commercial: No
BCN Advantage: Yes (for episodes starting on/after March 1, 2026)

ALL of the following

Blue Cross commercial fully insured: Yes
Blue Cross commercial self-funded: Yes
Medicare Plus Blue: Yes
BCN commercial: Yes
BCN Advantage: Yes
Decision maker: Blue Cross or BCN Utilization Management as applicable

ALL of the following

All listed products: Yes
Decision maker: TurningPoint

ALL of the following

All listed products: Yes (managed through Oncology Value Management program)
Decision maker: OncoHealth or Carelon depending on date/group; submit gene/cellular therapy PA via Medical and Pharmacy Drug PA Portal

ALL of the following

Blue Cross commercial: No
Blue Cross self-funded: No
Medicare Plus Blue: Not applicable
BCN commercial: No
BCN Advantage: Not applicable

ALL of the following

Blue Cross commercial: Yes
Blue Cross self-funded: Yes
Medicare Plus Blue: Yes (WellSky for stays starting on/after Jan. 5, 2026; Blue Cross UM before that)
BCN commercial: Yes
BCN Advantage: Yes (WellSky for stays starting on/after Jan. 5, 2026; BCN UM before that)

ALL of the following

Blue Cross commercial fully insured: Yes (Blue Cross Utilization Management for adult members on/after Nov. 3, 2025; Carelon before that)
Medicare Plus Blue: No
BCN commercial: Yes (BCN Utilization Management for adult members on/after Nov. 3, 2025)
BCN Advantage: No

Blue Cross commercial fully insured: Yes - TurningPoint

Blue Cross commercial self-funded: Yes (select groups) - TurningPoint

Medicare Plus Blue: Yes - TurningPoint

BCN commercial: Yes - TurningPoint

BCN Advantage: Yes - TurningPoint

ALL of the following

Blue Cross commercial fully insured: Yes - Blue Cross Human Organ Transplant team
Blue Cross commercial self-funded: Yes - Blue Cross Human Organ Transplant team
Medicare Plus Blue: No prior auth
BCN commercial: Yes - Human Organ Transplant team
BCN Advantage: No prior auth

Contact Blue Cross, BCN or the delegated vendor to request prior authorization.

Documentation Required

Submit pharmacy PAs via Medical and Pharmacy Drug PA Portal or ePA tools

Submit pharmacy-related prior authorization requests through the Medical and Pharmacy Drug PA Portal; alternately, electronic prior authorization tools such as CoverMyMeds are available.

Access the Medical and Pharmacy Drug PA Portal via the provider portal to submit pharmacy benefit drug PAs.
Use CoverMyMeds or other ePA tools as alternate submission options.

Prior Authorization

Pharmacy benefit drug prior authorization submission routes

For drugs covered under the pharmacy benefit, submit prior authorization requests through the Medical and Pharmacy Drug PA Portal (accessible via the provider portal/Availity) or through electronic prior authorization tools such as CoverMyMeds/ePA.

Medical and Pharmacy Drug PA Portal is the primary submission route.
CoverMyMeds and similar ePA tools are acceptable alternative submission methods.

Prior Authorization

Delegated vendors manage PAs for specific services

Certain services require prior authorization and those authorizations are managed by delegated vendors such as Carelon Medical Benefits Management, EviCore by Evernorth, TurningPoint, OncoHealth and WellSky depending on the service and product.

Carelon manages determinations for services like echocardiology where indicated.
EviCore and TurningPoint manage prior authorizations for select radiation, spine and musculoskeletal services.
OncoHealth and WellSky are referenced as managers for oncology/supportive care and post-acute care respectively.

Prior Authorization

Alacura manages non-emergency flight prior authorizations

Alacura Medical Transport Management manages prior authorizations for non-emergency flights for Blue Cross and BCN commercial members.

Alacura handles prior authorization for non-emergency air ambulance (commercial members).

Note

PAs vary by product and service (illustrative examples)

Prior authorization requirements vary by product and service; the document provides illustrative examples showing differing PA rules by product and service.

Example: Speech therapy (non-autism) — no prior auth for most Blue Cross products, but BCN commercial/BCN Advantage require EviCore.
PA requirements depend on product (Blue Cross commercial, BCN commercial, Medicare Plus Blue, BCN Advantage) and service type.

Prior Authorization

Prior authorization required for cervical and lumbar spine surgery (TurningPoint)

Spine surgery (cervical and lumbar) requires prior authorization for multiple products and is managed by TurningPoint for the listed lines.

TurningPoint is the decision maker for spine surgery PAs across Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage.
Self-funded groups may have select variations handled by TurningPoint as noted.

Prior Authorization

Transplant procedures require PA for most Blue Cross commercial products

Transplants require prior authorization for many Blue Cross commercial products and are managed by the Blue Cross Human Organ Transplant team; some products (Medicare Plus Blue, BCN Advantage) do not require prior authorization.

Blue Cross Human Organ Transplant team handles transplant PAs for Blue Cross commercial fully insured and self-funded groups.
Medicare Plus Blue and BCN Advantage do not require prior authorization for transplants per the summary.

Regional specificsEast and Southeast: submit referrals via e-referral. Mid, West and Upper Peninsula: referrals and plan notifications are not required.

Alacura Medical Transport Management

CompanyAlacura Medical Transport Management

RoleManages prior authorization of non-emergency flights for Blue Cross Blue Shield of Michigan and Blue Care Network members with commercial plans.

Applies toCommercial members of BCBSM and BCN (not Medicare/advantage per the cited text).

Availity

VendorAvaility

FunctionProvides provider portal and electronic data interchange (EDI) services for Blue Cross Blue Shield of Michigan and Blue Care Network.

UsagePrimary access point for provider electronic transactions referenced in the document (e.g., Medical and Pharmacy Drug PA Portal via provider portal).

Carelon Medical Benefits Management

CompanyCarelon Medical Benefits Management

RoleContracts with BCBSM and BCN to manage prior authorizations for select services; referenced as a delegated prior auth manager.

More infoRefer to authorizations.bcbsm.com for details on services managed by Carelon.

EviCore by Evernorth

CompanyEviCore by Evernorth

RoleContracts with BCBSM and BCN to manage prior authorizations for select services; identified as the PA manager for some BCN commercial services (e.g., speech therapy non-autism, BCN Advantage).

ReferenceFor services managed by EviCore, follow instructions on the authorizations site noted in the document.

Joint Venture Hospital Laboratories

OrganizationJoint Venture Hospital Laboratories

RoleProvides a statewide outpatient laboratory network and third‑party administration for outpatient lab services; manages prior authorizations for genetic testing for BCN commercial and BCN Advantage products.

Applies toMembers with Medicare Plus Blue, BCN commercial and BCN Advantage plans (network and PA admin functions).

Alacura Medical Transport Management (duplicate)

CompanyAlacura Medical Transport Management

Role (duplicate)Manages prior authorizations for non-emergency flights for Blue Cross and BCN commercial plans.

NoteReferenced in the statewide utilization management summary as the PA manager for air/non-emergency medical transport.

Availity (duplicate)

VendorAvaility

Role (duplicate)Provides the provider portal and EDI services used for PA submission and access to the Medical and Pharmacy Drug PA Portal.

ImplicationProviders should use Availity to access required electronic PA tools as described in the document.

Carelon Medical Benefits Management (duplicate)

CompanyCarelon Medical Benefits Management

Role (duplicate)Delegated prior authorization manager for specified services referenced in the utilization management summary.

GuidanceCheck authorizations.bcbsm.com for service-specific PA submission instructions tied to Carelon-managed services.

EviCore by Evernorth (duplicate)

VendorEviCore by Evernorth

Role (duplicate)Listed as a delegated PA manager for select services and products; used for BCN commercial determinations in some cases.

ActionFollow vendor instructions for services indicated as managed by EviCore in the utilization summary.

Joint Venture Hospital Laboratories (duplicate)

OrganizationJoint Venture Hospital Laboratories

Role (duplicate)Outpatient lab network provider and genetic testing PA administrator for specified BCN/Medicare products.

Applies toMedicare Plus Blue, BCN commercial and BCN Advantage members where indicated.

Northwood Inc.

CompanyNorthwood Inc.

RoleManages prior authorizations and a supplier network for durable medical equipment, prosthetics/orthotics, and medical supplies (including diabetes supplies) for BCBSM and BCN members.

Applies toReferenced as the PA/supplier manager for DME and diabetes supplies across applicable products.

OncoHealth

CompanyOncoHealth

RoleProvides cancer support services to Blue Cross Blue Shield of Michigan and Blue Care Network.

ContextSupports oncology and supportive care programs referenced in the utilization management summary.

Tango and WellSky

CompaniesTango and WellSky

RoleReview member health care services for appropriateness and medical necessity on behalf of BCBSM and BCN.

Use caseWellSky is also referenced as the manager for certain post-acute care prior authorizations effective on specified dates.

TurningPoint Healthcare Solutions LLC

CompanyTurningPoint Healthcare Solutions LLC

RoleManages prior authorizations for musculoskeletal surgical and related procedures (e.g., spine surgery, joint surgery) for BCBSM and BCN.

ExamplesReferenced as the decision maker for spine surgery (cervical and lumbar) and joint surgery per the utilization management summary.