A Blue Care Network prior authorization form is submitted by your healthcare provider, not by you, to confirm that a planned service is medically necessary and covered before BCN will pay for it. Your role is to help your provider’s office gather the right information, confirm the request was sent, and know what your options are if it comes back denied. Under Michigan’s Public Act 60 of 2022, BCN has to issue a decision within nine calendar days for standard requests and 72 hours for urgent ones.1
Who Submits the Form
Only your provider can submit a prior authorization request. BCN does not accept forms directly from members. That means the practical work on your end is making sure the ordering provider’s office has your current member ID, knows the procedure or drug being requested, and has the clinical records that support medical necessity. If the request is going to a specialist, confirm which office is responsible for submitting it. A referral and a prior authorization are not the same thing, and a request that falls between two offices is a request that doesn’t get sent.
When Prior Authorization Is Required
BCN requires prior authorization across a broad set of service categories. Your provider’s billing staff will usually know what triggers it, but it helps to anticipate the common ones:
- All acute-care inpatient admissions, including medical, surgical, and behavioral health
- Orthopedic and spinal surgeries, managed through TurningPoint Healthcare Solutions
- Pain management services for BCN commercial members
- Skilled nursing, long-term acute care, and inpatient rehabilitation stays
- Durable medical equipment shipped to or purchased in Michigan, handled by Northwood
- Home health care episodes
- Chiropractic office visits, X-rays, manipulations, and physical medicine codes
- Bariatric surgery, which requires contacting BCN Utilization Management before the procedure
- Non-emergency air ambulance, authorized by Alacura Medical Transport Management for commercial members
- Many specialty and medical benefit drugs, including high-cost medications for conditions like rheumatoid arthritis or cancer
Emergency room visits and urgent care visits do not require prior authorization. Your provider does not need to seek advance approval when you need emergency stabilization or when you walk into an urgent care facility. For out-of-network providers located outside Michigan who do not hold a contract with their local Blue Cross Blue Shield plan, the rule flips: every service requires prior authorization except emergency and urgent care.
What Goes on the Form
Whether the request moves electronically or on paper, the same core information is required. Your provider’s office will need:
- Your BCN member ID number from the front of your insurance card
- The provider’s 10-digit National Provider Identifier
- ICD-10 diagnosis codes describing your condition
- CPT procedure codes identifying the exact service, test, or surgery being requested
- Clinical documentation: recent office notes, lab results, imaging reports, and records of any conservative treatments already tried
Clinical documentation is what the BCN reviewer uses to evaluate medical necessity. Incomplete records are one of the most common reasons a request stalls. For prescription drugs covered under the medical benefit, providers use the Medication Authorization Request Form, available on BCN’s authorizations site at authorizations.bcbsm.com. Pharmacy benefit drugs have their own forms and submission pathways.
How Providers Submit the Request
BCN offers three channels: electronic, fax, and mail. The right one depends on the service and the member’s plan.
e-Referral (Electronic)
The e-referral system is BCN’s primary portal, reached through the provider site that routes through Availity at apps.availity.com. Electronic submission confirms receipt immediately, accepts PDF attachments for clinical records, and avoids the quality problems that make faxed handwritten notes unreadable. For inpatient cases, e-referral also handles peer-to-peer review requests when a denial needs to be discussed with a medical director.
Fax (Drug Requests)
Drug prior authorization requests use dedicated fax lines that route to the right clinical team. The number depends on the plan and whether the drug falls under the medical or pharmacy benefit:
- BCN commercial, medical benefit drugs: 1-877-325-5979
- BCN commercial, pharmacy benefit drugs: 1-866-601-4425
- BCN Advantage, medical benefit drugs: 1-866-392-6465
- BCN Advantage, pharmacy benefit drugs: 1-800-459-8027
Sending a request to the wrong fax line is a common cause of delay. Confirm whether the plan is commercial or Advantage and whether the drug is a medical or pharmacy benefit before sending.
Medical and pharmacy drug requests can also be mailed to:
BCBSM Specialty Pharmacy Program
P.O. Box 312320
Detroit, MI 48231-2320
Mail is the slowest option. Michigan’s decision deadlines run from the date BCN receives the request, so any time the envelope spends in transit is time off the clock before the review even begins.
How Long BCN Has to Decide
Public Act 60 of 2022 sets binding timelines. For a standard request, BCN must issue a determination no later than nine calendar days after receipt. For an urgent request, where your life or health is at immediate risk, the decision must come within 72 hours.
If the reviewer needs more clinical information, BCN has to ask the provider for it within five calendar days of receiving the original request, and the notice must say exactly what is needed. Once the provider sends the additional records, or the submission deadline passes, a new nine-day clock starts for the final decision.
The requesting provider gets the decision through e-referral or by fax. You will receive a letter by mail or a notification through your BCN online account. An approval notice tells you how long the authorization lasts. Under BCN’s PA 60 policy, approvals are valid for at least 60 days or for whatever period is clinically appropriate, whichever is longer. Prescription drug approvals vary by medication, running anywhere from 60 days to a full year.
If the Request Is Denied
A denial is not the end of the road, but the order of the next steps matters.
Peer-to-Peer Review
Before filing a formal appeal, your treating or ordering physician can ask for a peer-to-peer conversation with a BCN medical director to walk through the clinical reasoning. This option is only available for denials based on medical necessity, and the provider has to request it before filing a provider appeal. Once an appeal is filed, the peer-to-peer window closes. For inpatient admissions outside behavioral health, the request has to be submitted within seven business days of the denial date. Providers at Michigan facilities use e-referral; those outside Michigan fax the Physician Peer-to-Peer Request Form to 1-866-373-9468 or email it to peertopeer@bcbsm.com during business hours. If the physician misses the scheduled call or declines to participate, it is not rescheduled, and the only remaining path is a formal appeal.
Internal Appeal
If peer-to-peer does not reverse the denial, or your provider skips it, a first-level provider appeal can be filed. Federal rules give you 180 days from the date you receive the denial notice to file an internal appeal. A second-level appeal is available if the first is denied, and the second-level decision is binding within BCN’s internal process.
External Review
After internal appeals are exhausted, you can request an external review by an Independent Review Organization unaffiliated with BCN. The written request has to be filed within four months of the final internal denial. The reviewer must issue a decision within 45 days for a standard case, or 72 hours if the case is medically urgent. There is no fee if BCN uses the HHS-administered federal external review process; a state process or contracted reviewer cannot charge more than $25.
Mental Health and Substance Use Requests
If the prior authorization is for mental health or substance use disorder treatment, federal law restricts how strictly BCN can apply the requirement. The Mental Health Parity and Addiction Equity Act treats prior authorization as a nonquantitative treatment limitation, which cannot be applied more stringently to behavioral health benefits than to comparable medical and surgical benefits. BCN cannot demand more documentation, use shorter approval windows, or apply tougher medical necessity criteria for a behavioral health request than it would for an analogous medical one. A denial that reflects a stricter standard is itself a basis for appeal.
If Your Provider Leaves the Network Mid-Treatment
An approved prior authorization can be disrupted if your in-network provider’s contract with BCN ends while you are in the middle of treatment. Under the federal No Surprises Act, if you qualify as a continuing care patient, BCN has to notify you of the network change and give you the option to keep seeing the departing provider under the same in-network terms and cost-sharing for up to 90 days from the date of notification. The provider has to accept BCN’s payment and your cost-sharing as payment in full and continue following BCN’s quality standards for that period. An approved treatment plan does not have to collapse because of a contract dispute you were not part of.