Currentblue cross blue shield - michiganPolicy N/A

Preview questionnaires and medical necessity criteria

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Lists services that require prior authorization and identifies the preview questionnaire or InterQual Connect guideline used to collect provider responses for Blue Cross Blue Shield of Michigan commercial, Medicare Plus Blue, and BCN Advantage members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyPreview questionnaires and medical necessity criteria

Policy CodePolicy N/A

Change TypeAdministrative mapping (no material clinical changes)

Effective DateApr 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionComplete the listed preview questionnaire or InterQual Connect guideline in the e-referral system before submitting a prior authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservices listed with preview questionnaires

InterQualInterQual referenced

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Currentblue cross blue shield - michiganPolicy N/A

Preview questionnaires and medical necessity criteria

Customize your policy alerts

Sign up for all blue cross blue shield - michigan policy alerts

Know when blue cross blue shield - michigan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerblue cross blue shield - michigan

PolicyPreview questionnaires and medical necessity criteria

Policy CodePolicy N/A

Change TypeAdministrative mapping (no material clinical changes)

Effective DateApr 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionComplete the listed preview questionnaire or InterQual Connect guideline in the e-referral system before submitting a prior authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservices listed with preview questionnaires

InterQualInterQual referenced

Coverage Determination Sources and Scope

Mapping to criteria sources

Coverage determinations are made using the specified criteria source for each listed service.

General prior authorization mapping: For each listed service, the payer requires completion of the listed Preview questionnaire or InterQual Connect guideline and will apply the Criteria source (InterQual, specific medical policy, or NCD/LCD) to determine medical necessity.

The document lists services and the applicable criteria source but does not reproduce the criteria themselves.

This document does not reproduce the full clinical coverage criteria. For medical necessity rules, providers must refer to the named Criteria source for each service — typically InterQual procedure criteria, a specific Blue Cross Blue Shield of Michigan medical policy, or an applicable NCD/LCD — as identified in the Criteria source column of the service table. The document lists which criteria source applies and which Preview questionnaire or InterQual Connect guideline must be completed, but it does not include the underlying clinical criteria text.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for specific services listed in the policy (for example: balloon ostial dilation, septoplasty, gastric pacing/stimulation, hammertoe correction, and others shown in the preview questionnaires table). Providers must obtain prior authorization when a service row in the criteria table indicates required authorization for their patient’s line of business.

Examples include: balloon ostial dilation; septoplasty; gastric pacing/stimulation; hammertoe correction surgery; select varicose vein treatments.

Note

Step Therapy Not Applicable

Some services do not define step therapy requirements in this document. If a service has no step therapy content noted here, step therapy is not applicable for that service within this policy.

Documentation Required

Complete Preview Questionnaire or InterQual Connect

Complete the preview questionnaire shown in the related documents column for the service or complete the InterQual Connect guideline questions in the e-referral system before submitting a prior authorization request. Preview questionnaires list the questions you will be asked so you can prepare answers ahead of time.

If the related documents column shows "Preview questionnaire," prepare answers from that questionnaire in the e-referral system.
If the related documents column shows "None - complete the InterQual Connect guideline questions", complete InterQual Connect in the e-referral system.

Denial Risk

Missing Questionnaire May Impede Prior Authorization

Failure to complete the appropriate preview questionnaire or the InterQual Connect questions in the e-referral system may prevent processing of the prior authorization request and can lead to delays or denials.

Do not submit a prior authorization request without the completed questionnaire or completed InterQual Connect responses when required.

Key Terms

Preview questionnaire

DefinitionPreview questionnaires show the questions you'll need to answer within the questionnaire that opens in the e-referral system so you can prepare your answers ahead of time.

PurposeUsed by providers to prepare responses ahead of submitting a prior authorization request in the e-referral system.

VariationsMore than one preview questionnaire may be listed for a service when a different questionnaire opens by line of business or when a trigger questionnaire opens followed by an additional questionnaire.

Action requiredComplete the listed preview questionnaire(s) in the e-referral system for the service being requested to enable the payer to make a prior authorization determination.

Where to find criteriaThe Criteria source column in the table specifies the criteria used to make determinations (InterQual, medical policy, NCD/LCD).

Policy Purpose and Scope

This administrative guide links listed services to the corresponding Preview questionnaires and to the medical necessity criteria used for prior authorization determinations. Providers must prepare answers using the Preview questionnaire for the service or complete the InterQual Connect guideline questions in the e-referral system where indicated. For Medicare Advantage members, determinations reference NCDs/LCDs from the Medicare Coverage Database where applicable, and InterQual or medical policy criteria are used as specified in the Criteria source column.