CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Preview questionnaires and medical necessity criteria

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This document lists services that require prior authorization and the preview questionnaires and medical necessity criteria used by Blue Cross Blue Shield of Michigan and Blue Care Network for Medicare Plus Blue, BCN commercial, and BCN Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPreview questionnaires and medical necessity criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review DateN/A

Key ActionPrepare answers to the preview questionnaire items in the e-referral system before submitting the prior authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservices listed with preview questionnaires

InterQualexternal clinical criteria used

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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 TypeNo material change

Effective DateFeb 1, 2026

Last ReviewFeb 1, 2026

Next Review DateN/A

Key ActionPrepare answers to the preview questionnaire items in the e-referral system before submitting the prior authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservices listed with preview questionnaires

InterQualexternal clinical criteria used

Coverage Determination and Criteria

General coverage determination process

Services listed in this document are subject to coverage determinations when prior authorization is required and are evaluated against the specified criteria source.

Service entry: Each listed service is evaluated using the specified criteria source (for example, a named medical policy, InterQual procedure criteria, or a Medicare NCD/LCD).

The document provides per-service indication of which lines of business require prior authorization and which criteria source applies; the full medical necessity decision logic resides in the referenced criteria sources.

This document does not itself enumerate explicit exclusions for services. Where exclusions apply, they are identified and enforced within the referenced medical policies, Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or other criteria sources cited for each service. Providers should consult the specific referenced policy or Medicare coverage determination named for a service to confirm any exclusions that affect coverage or prior authorization requirements.

Decisions that a service is not medically necessary are based on the medical necessity criteria specified for each service rather than on standalone statements in this document. Determinations reference the cited sources (for example, InterQual criteria, internal medical policies, LCDs or NCDs) listed alongside each service entry; if those referenced documents indicate the service does not meet medical necessity criteria, the service will be denied as not medically necessary.

Services and Coding References

Services referenced (no explicit codes listed)mixed

No codes listed

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for the services listed in this policy. Failure to obtain prior authorization when required may result in denial of payment.

Applies to Medicare Plus Blue, BCN commercial and BCN Advantage where indicated.
Preview questionnaires must be completed in the e-referral system.
Medical necessity determinations use InterQual, NCDs/LCDs, and Blue Cross medical policies as applicable.

Note

Prepare Questionnaire Responses

Preview questionnaires list the specific questions you'll be asked in the e-referral system. Review these preview questionnaires and have answers ready before submitting the prior authorization request to avoid delays.

A different questionnaire may open depending on line of business.
Trigger questionnaires may open first and then prompt additional questionnaires.

Background and Evidence Sources

Blue Cross Blue Shield of Michigan and Blue Care Network use a combination of external and internal criteria when assessing prior authorization requests. The primary sources include InterQual clinical criteria, applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), and the payer’s own medical policies. Each listed service is evaluated against the specific criteria source identified for that service; the full medical necessity logic and any exclusions reside in those referenced documents. Preview questionnaires in the e-referral system show the questions providers must answer to support a prior authorization request and may differ by line of business or trigger additional questionnaires.

Definitions and Criteria Sources

Preview questionnaire

DefinitionA list of questions that show what must be answered within the e-referral system to support a prior authorization request; may differ by line of business or trigger additional questionnaires.

PurposeLets providers prepare answers ahead of submitting a prior authorization request by previewing the items that will appear in the e-referral questionnaire.

Variability by line of businessA different questionnaire may open in the e-referral system depending on the member line of business (e.g., commercial vs. Medicare Advantage).

Trigger questionnairesSome services present a trigger questionnaire first in the e-referral system; completion of the trigger can open additional questionnaires.

Provider action (most actionable)Prepare and complete the listed preview questionnaire responses in the e-referral system before submitting the prior authorization to avoid delays or denials.

Prior Authorization

Services Requiring Prior Authorization — examples

Examples of services with preview questionnaires and the criteria source include (not exhaustive): Balloon ostial dilation — preview questionnaire; criteria: Balloon Dilation for Treatment of Chronic Sinusitis medical policy. Blepharoplasty and repair of brow ptosis — preview questionnaire; criteria: Blepharoplasty and Repair of Brow Ptosis medical policy. Rhinoplasty, septoplasty, sacral nerve neuromodulation/stimulation and temporomandibular joint surgery also have preview questionnaires and specified criteria sources (InterQual, Local Coverage Determinations, or applicable medical policies).

Balloon ostial dilation: Prior authorization required across Medicare Plus Blue, BCN commercial and BCN Advantage.
Blepharoplasty and repair of brow ptosis: Prior authorization required across Medicare Plus Blue, BCN commercial and BCN Advantage.
Refer to the policy table for line-of-business specific prior authorization indicators and criteria sources.

DefinitionThe medical necessity criteria used to make determinations on prior authorization requests, which may include InterQual, Medicare NCDs/LCDs, or internal Blue Cross medical policies.

Medicare Advantage basisFor Medicare Advantage members, determinations are based on national coverage determinations, local coverage determinations, and other applicable Medicare criteria; internal criteria may be used when permitted by Medicare statutes and regulations.

InterQual useBlue Cross licenses InterQual to assist in creating internal coverage criteria and will use InterQual procedure criteria when available.

When InterQual unavailableIf InterQual criteria are unavailable, Blue Cross will use its own medical policies developed in accordance with Medicare statutes and approved by the Blue Cross Utilization Management Committee.

Where to find criteria (operational)InterQual: access via One Healthcare ID; NCDs/LCDs: Medicare Coverage Database; Medical policies: Medical Policy Router Search on bcbsm.com.