Summary of utilization management programs

for Michigan providers

For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

The tables that follow are not all-inclusive lists of procedures and services that require authorization. For more
information, visit ereferrals.bcbsm.com.
Note: This document is for summary purposes only. For Blue Cross commercial members, not all services in
the categories listed require authorization for every employer group. The lists of groups identified as excluded
from specific authorization requirements are not all-inclusive. Providers are responsible for identifying the need
for authorization our provider portal (availity.com*) or through Provider Inquiry and for contacting the vendor
and obtaining authorization for the service.

Behavioral health services (mental health and substance use disorders)

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Refer to the Blue Refer to the Blue Refer to the Blue Refer to BCN’s Refer to BCN’s
Cross Behavioral Cross Behavioral Cross Behavioral Behavioral Health Behavioral Health
Health page Health page Health page page. page.
Routine outpatient therapy No No No No No
in clinic or provider office
Outpatient autism Yes Yes, if the group No Yes Yes
services (applied behavior New Directions opts into the BCN Behavioral BCN Behavioral
analysis) standard Health Health
BlueCross autism
program
New Directions
Outpatient ECT and No No No Yes Yes
neurofeedback BCN Behavioral BCN Behavioral
Health Health
Outpatient TMS Yes Yes, if the group No Yes Yes
New Directions offers the TMS BCN Behavioral BCN Behavioral
benefit Health Health
New Directions
Initial inpatient, residential Yes Yes Yes** Yes Yes*
or partial hospital New Directions New Directions Blue Cross BCN Behavioral BCN Behavioral
Behavioral Health Health Health
Intensive outpatient No No Yes Yes Yes
treatment Blue Cross BCN Behavioral BCN Behavioral
Behavioral Health Health Health
Subacute detox Yes Yes Yes Yes Yes
New Directions New Directions Blue Cross BCN Behavioral BCN Behavioral
Behavioral Health Health Health

**Note: Medicare Plus Blue and BCN Advantage don’t have a residential mental health treatment benefit.

1
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Non-behavioral health services

Procedure or Is authorization required? / Who makes the determinations?
service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Air ambulance Yes Yes No Yes No
Alacura Medical Alacura Medical Alacura Medical
Transport Transport Transport
Management, for Management, for Management, for
non-emergency non-emergency non-emergency
flights only flights only flights only
Refer to the Blue Refer to the Blue Refer to BCN’s
Cross Authorization Cross Authorization Authorization
Requirements & Requirements & Requirements &
Criteria page. Criteria page. Criteria page.
Cardiology No No Yes Yes Yes
(See also: AIM Specialty AIM Specialty AIM Specialty
Echocardiology) Health®, for dates Health, for dates of Health, for dates of
of service on or service on or after service on or after
after May 1, 2019. Oct. 1, 2018 Oct. 1, 2018
Refer to the Blue Refer to BCN’s AIM- Refer to BCN’s AIM-
Cross AIM-Managed Managed Procedures Managed Procedures
Procedures page. page. page.
Chiropractic services No No No Yes Yes
BCN Utilization BCN Utilization
Management Management
Durable medical Yes No Yes Yes Yes
equipment Northwood, Inc., for Northwood, Inc., for Northwood, Inc. Northwood, Inc.
dates of service on dates of service on or
or after Jan. 1, 2021 after May 1, 2019
Echocardiology Yes Yes Yes Yes Yes
(See also: Cardiology) AIM Specialty AIM Specialty AIM Specialty AIM Specialty AIM Specialty
Health Health: Health, for dates of Health, for dates of Health, for dates of
For all groups except service on or after service on or after service on or after
Refer to the Blue UAW Retiree Medical
May 1, 2019 Oct. 1, 2018 Oct. 1, 2018
Benefits Trust, Blue
Cross AIM-Managed Cross and Blue Shield
Procedures page. Federal Employee Refer to the Blue Refer to BCN’s Refer to BCN’s
Program®, State of Cross AIM-Managed AIM-Managed AIM-Managed
Michigan plans and
select Ascension Health Procedures page. Procedures page. Procedures page.
groups

Refer to the Blue

Cross AIM-
Managed
Procedures page.
Genetic and No No No Yes Yes
molecular testing Joint Venture Joint Venture
Hospital Hospital
Laboratories Laboratories

2
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Home health care No No Yes No Yes
services CareCentrix , for
®
CareCentrix®, for
episodes of care episodes of care
starting on or after starting on or after
June 1, 2021 June 1, 2021
For episodes For episodes
starting prior to starting prior to
June 1, 2021, June 1, 2021,
providers will need providers will need
to request to request
authorization only authorization only
when one of the when one of the
following occurs following occurs
after June 1, 2021: after June 1, 2021:
Recertification or Recertification or
resumption of care resumption of care
is needed, or a is needed, or a
significant change significant change
in condition. in condition.
Refer to the Blue Refer to the BCN
Cross Home Health Home Health care
care page. page.
Inpatient admissions, Yes Yes Yes Yes Yes
acute care Blue Cross Blue Cross Blue Cross BCN Utilization BCN Utilization
(hospitals) Utilization Utilization Utilization Management Management
Management Management Management
Refer to BCN’s Refer to BCN’s
Refer to the Blue Refer to the Blue Refer to the Blue Authorization Authorization
Cross Authorization Cross Cross Authorization Requirements & Requirements &
Requirements & Authorization Requirements & Criteria page. Criteria page.
Criteria page. Requirements & Criteria page.
Criteria page.
Joint surgery – knee, Yes Yes, for select Yes Yes Yes
hip, shoulder TurningPoint groups TurningPoint TurningPoint TurningPoint
See the “Orthopedic For dates of service TurningPoint For dates of service For dates of service For dates of service
procedure codes” on or after Jan. 1, For UAW Retiree on or after July 1, on or after July 1, on or after July 1,
2021, authorization Medical Benefits Trust 2020, authorization 2020, authorization 2020, authorization
section of the non-Medicare members,
Musculoskeletal is required for for dates of service on or is required for is required for is required for
procedure codes that procedure codes in after May 31, 2021 procedure codes in procedure codes in procedure codes in
require authorization by the document linked the document the document the document
Authorization is
at left. linked at left. linked at left. linked at left.
TurningPoint document. required for
(See also: Refer to the Blue procedure codes Refer to the Blue Refer to the BCN Refer to the BCN
Musculoskeletal Cross in the document Cross Musculoskeletal Musculoskeletal
procedures, other) Musculoskeletal linked at left. Musculoskeletal Services page. Services page.
Services page. Services page.
Refer to the Blue
Cross
Musculoskeletal
Services page.

3
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Medical oncology Yes Yes, for select Yes Yes Yes
(See also: Radiation Medical oncology groups Medical oncology Medical oncology Medical oncology
oncology) and supportive AIM Specialty and supportive care and supportive care and supportive care
care drugs Health drugs require drugs require drugs require
require To determine which authorization authorization authorization
authorization groups have opted in through AIM through AIM through AIM
and the date on which
through AIM they opted in, see the Specialty Health Specialty Health Specialty Health
Specialty Health AIM medical oncology (starting Jan. 1, (starting Aug. 1, (starting Jan. 1,
(starting Dec. 1, prior authorization
program opt-in list for
2020) 2019) 2020)
2020) Blue Cross commercial
Includes MESSA self-funded groups. Note: CAR-T cell Note: For CAR-T Note: CAR-T cell
members, for dates of therapy drugs cell therapy only, therapy drugs
service on or after Jan. Note: For CAR-T require authorization require
1, 2022 cell therapy only, authorization required through authorization
Note: For CAR-T authorization through NovoLogix NovoLogix. through NovoLogix
cell therapy only, required through (not through AIM) (not through AIM)
NovoLogix. when administered Refer to BCN’s when administered
authorization Medical Benefit
required through in an outpatient in an outpatient
Refer to the Blue Drugs page.
NovoLogix®. setting for dates of setting for dates of
Cross Medical
service on or after service on or after
Refer to the Blue Benefit Drugs
Jan. 1, 2021. For Jan. 1, 2021. For
Cross Medical page.
dates of service dates of service
Benefit Drugs page. prior to Jan. 1, prior to Jan. 1,
2021, CAR-T cell 2021, CAR-T cell
therapy is covered therapy is covered
under Original under Original
Medicare. Medicare.
Refer to the Blue Refer to BCN’s
Cross Medical Medical Benefit
Benefit Drugs page. Drugs page.
Musculoskeletal Yes Yes, for select Yes Yes Yes
procedures, other TurningPoint groups TurningPoint TurningPoint TurningPoint
See the “Orthopedic For dates of service TurningPoint For dates of service For dates of service For dates of service
procedure codes” on or after Jan. 1, For UAW Retiree on or after July 1, on or after July 1, on or after July 1,
section of the 2021, authorization Medical Benefits Trust 2020, authorization is 2020, authorization is 2020, authorization is
non-Medicare members,
Musculoskeletal is required for for dates of service on or required for required for required for
procedure codes that procedure codes in after May 31, 2021 procedure codes in procedure codes in procedure codes in
require authorization by the document linked the document linked the document linked the document linked
Authorization is
TurningPoint document. at left. at left. at left. at left.
required for
(See also: Joint surgery Refer to the Blue procedure codes Refer to the Blue Refer to the BCN Refer to the BCN
– knee, hip, shoulder) Cross in the document Cross Musculoskeletal Musculoskeletal
Musculoskeletal linked at left. Musculoskeletal Services page for Services page for
Services page. Services page for more information. more information.
Refer to the Blue
more information.
Cross
Musculoskeletal
Services page.

4
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Pain management Yes Yes, for select Yes Yes Yes
See the “Pain For dates of groups For dates of For dates of For dates of
management procedure service on or after TurningPoint service on or after service on or after service on or after
codes” section of the Jan. 1, 2021, Jan. 1, 2021, Jan. 1, 2021, Jan. 1, 2021,
TurningPoint For UAW Retiree TurningPoint TurningPoint TurningPoint
Musculoskeletal Medical Benefits Trust
procedure codes that non-Medicare members,
Authorization is Authorization is Authorization is Authorization is
require authorization by for dates of service on or
TurningPoint document. required for after May 31, 2021 required for required for required for
procedure codes in procedure codes in procedure codes in procedure codes in
the document linked Refer to the Blue the document the document the document
at left. Cross linked at left. linked at left. linked at left.
Musculoskeletal
Refer to the Blue Services page. Refer to the Blue Refer to the BCN Refer to the BCN
Cross Cross Musculoskeletal Musculoskeletal
Musculoskeletal Musculoskeletal Services page. Services page.
Services page. Services page.
For dates of For dates of
For dates of For dates of service before service before
service before Jan. service before Jan. 1, 2021, Jan. 1, 2021,
1, 2021, eviCore Jan. 1, 2021, eviCore healthcare eviCore healthcare
healthcare: For all eviCore healthcare
groups except Michigan Refer to BCN’s Refer to BCN’s
Education Special Services Refer to the Blue eviCore-Managed eviCore-Managed
Association
Cross eviCore- Procedures page. Procedures page.
Refer to the Blue Managed
Cross eviCore- Procedures page.
Managed
Procedures page.

Physical, No No Not applicable No, for members Not applicable

occupational and under age 19
speech therapy with
Yes, for members
an autism diagnosis 19 and older,
through eviCore
healthcare
Includes physical
medicine services
by chiropractors
(starting May 27,
2019) and by
athletic trainers (for
dates of service on
or after Jan. 1,
2021)
Refer to BCN’s
Outpatient PT, OT,
ST page.

5
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Physical and No No No, for dates of Yes Yes
occupational therapy service on or after eviCore healthcare eviCore healthcare
with a non-autism April 1, 2022
Includes physical Refer to BCN’s
diagnosis
medicine services Outpatient PT, OT,
Yes, for dates of by chiropractors ST page..
service prior to (starting May 27,
April 1, 2022 2019) and by
eviCore healthcare athletic trainers (for
will accept dates of service on
retroactive or after Jan. 1,
authorization 2021)
requests through
July 29, 2022. Refer to BCN’s
Outpatient PT, OT,
Refer to the Blue ST page.
Cross eviCore-
Managed
Procedures page.
Post-acute care Yes (notification Yes Yes Yes Yes
(SNF, rehab, LTAC) only) (notification naviHealth, for BCN Utilization naviHealth, for
Blue Cross only) members admitted Management members admitted
Utilization Blue Cross on or after June 1, on or after June 1,
2019 Refer to BCN’s 2019
Management Utilization Authorization
Management Refer to the Blue Requirements & Refer to BCN’s
Refer to the Blue
Cross Authorization Refer to the Blue Cross Authorization Criteria page. Authorization
Requirements & Cross Requirements & Requirements &
Criteria page. Authorization Criteria page Criteria page.
Requirements &
Criteria page.
Proton beam therapy Yes Yes Yes Yes Yes
(For information about AIM Specialty AIM Specialty eviCore healthcare eviCore healthcare eviCore healthcare
other radiation oncology Health: Health, for dates
procedures, see For Michigan Education of service on or Refer to the Blue Refer to BCN’s Refer to BCN’s
Radiation oncology
Special Services
after Jan. 1, 2019: Cross eviCore- eviCore-Managed eviCore-Managed
Association only
below) For all groups, including Managed Procedures page. Procedures page.
Refer to the Blue UAW Retiree Medical Procedures page.
Cross AIM-Managed Benefits Trust non-
Medicare members.
Procedures page. Exceptions:
UAW Retiree Healthcare
Trust (group 70605) and
eviCore healthcare, UAW International Union
for dates of service (group 71714), Blue
Cross and Blue Shield
on or after Jan. 1, Federal Employee
2018: Program, State of
For all groups except Michigan plans and
Michigan Education Special select Ascension Health
Services Association groups

Refer to the Blue Refer to the Blue

Cross eviCore- Cross AIM-
Managed Managed
Procedures page. Procedures page.

6
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross
commercial fully
insured groups
Radiation oncology, Yes
other than proton eviCore healthcare:
beam therapy For all groups except
Michigan Education Special
(For information about Services Association
proton beam therapy,
see Proton beam Refer to the Blue
Cross eviCore-
therapy above.)
Managed
Procedures page.
Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial self-
funded groups
Yes Yes Yes Yes
AIM Specialty eviCore healthcare eviCore healthcare eviCore healthcare
Health, for dates of
Refer to the Blue Refer to BCN’s Refer to BCN’s
service on or after
Cross eviCore- eviCore-Managed eviCore-Managed
Jan. 1, 2019: Managed Procedures page. Procedures page.
For UAW Retiree Medical
Benefits Trust non- Procedures page
Medicare members only
except UAW Retiree
Healthcare Trust (group
70605) and UAW
International Union (group
71714)

Refer to the Blue

Cross AIM-
Managed
Procedures page.

Radiology Yes Yes Yes Yes Yes

procedures (high- AIM Specialty AIM Specialty AIM Specialty AIM Specialty AIM Specialty
tech imaging) Health Health: Health Health, for dates of Health, for dates of
For all groups, including service on or after service on or after
Refer to the Blue Blue Cross and Blue Refer to the Blue Oct. 1, 2018 Oct. 1, 2018
Shield Federal Employee
Cross AIM-Managed Program for dates of
Cross AIM-
Procedures page. service on or after Feb. Managed Refer to BCN’s Refer to BCN’s
1, 2021. Procedures page. AIM-Managed AIM-Managed
Excluded are State of Procedures page. Procedures page.
Michigan plans and
select Ascension Health
groups

Refer to the Blue

Cross AIM-
Managed
Procedures page.

Sleep studies Yes Yes Yes Yes Yes

AIM Specialty AIM Specialty AIM Specialty BCN Utilization BCN Utilization
Health Health: Health, for dates of Management Management
For all groups except service on or after
Refer to the Blue Blue Cross and Blue
May 1, 2019 Refer to BCN’s Refer to BCN’s
Shield Federal Employee
Cross AIM-Managed Program, State of
Sleep Management Sleep Management
Procedures page. Michigan plans and Refer to the Blue Program page. Program page.
select Ascension Health Cross AIM-
groups
Managed
Refer to the Blue Procedures page.
Cross AIM-
Managed
Procedures page.

Speech therapy with No No No Yes Yes

a non-autism eviCore healthcare eviCore healthcare
diagnosis
Refer to BCN’s Refer to BCN’s
Outpatient PT, OT, Outpatient PT, OT,
ST page.. ST page.

7
 Summary of utilization management programs
for Michigan providers
For Blue Cross commercial, Medicare Plus BlueSM,
Blue Care Network commercial and BCN AdvantageSM

Revised August 2022

Procedure or Is authorization required? / Who makes the determinations?

service Blue Cross Blue Cross Medicare Plus Blue BCN commercial BCN Advantage
commercial fully commercial self-
insured groups funded groups
Spine surgery – Yes Yes, for select Yes Yes Yes
cervical TurningPoint groups TurningPoint TurningPoint TurningPoint
See the “Spinal For dates of service TurningPoint For dates of service Authorization is Authorization is
procedure codes” on or after Jan. 1, For UAW Retiree
on or after Jan. 1, required for required for
section of the 2021, authorization Medical Benefits Trust 2021, authorization procedure codes in procedure codes in
Musculoskeletal is required for non-Medicare members, is required for the document the document
for dates of service on or
procedure codes that procedure codes in after May 31, 2021
procedure codes in linked at left. linked at left.
require authorization by the document linked the document
at left. Authorization is linked at left. Refer to the BCN Refer to the BCN
TurningPoint document. Musculoskeletal Musculoskeletal
required for
Refer to the Blue procedure codes Refer to the Blue Services page. Services page.
Cross in the document Cross
Musculoskeletal linked at left. Musculoskeletal
Services page. Services page.
Refer to the Blue
Cross
Musculoskeletal
Services page.
Spine surgery – Yes Yes, for select Yes Yes Yes
lumbar For dates of groups For dates of TurningPoint TurningPoint
See the “Spinal service on or after TurningPoint service on or after
Jan. 1, 2021, Jan. 1, 2021, Authorization is Authorization is
procedure codes” For UAW Retiree required for required for
TurningPoint TurningPoint
section of the Medical Benefits Trust
procedure codes in procedure codes in
non-Medicare members,
Musculoskeletal Authorization is for dates of service on or Authorization is the document the document
procedure codes that required for after May 31, 2021 required for linked at left. linked at left.
require authorization by procedure codes in procedure codes in
the document linked Authorization is the document Refer to the BCN Refer to the BCN
TurningPoint document.
at left. required for linked at left. Musculoskeletal Musculoskeletal
procedure codes Services page. Services page.
Refer to the Blue in the document Refer to the Blue
Cross linked at left. Cross
Musculoskeletal Musculoskeletal
Services page. Refer to the Blue Services page.
Cross
For dates of service Musculoskeletal For dates of
before Jan. 1, 2021, Services page. service before
eviCore healthcare: Jan. 1, 2021,
For all groups except eviCore healthcare
Michigan Education Special
Services Association
Refer to the Blue
Refer to the Blue Cross eviCore-
Cross eviCore- Managed
Managed Procedures page
Procedures page
Transplants Yes Yes No Yes Yes
Blue Cross Blue Cross BCN Utilization BCN Utilization
Utilization Utilization Management Management
Management Management

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