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It enables healthcare providers to formally submit clinical details for coverage review when prior contact with Provider Relations and Servicing has not resolved the inquiry. The document requires essential provider information, patient identification details, and specific medical billing data, including procedure, HCPCS, and ICD-10 diagnosis codes, to facilitate an efficient and accurate authorization determination process.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/blue-cross-blue-shield-of-michigan-request-for-preauthorization-form/287771/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/blue-cross-blue-shield-of-michigan-request-for-preauthorization-form/287771.png","ImageObject",442,249,{"name":88,"@type":89},"Aran","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should medical providers submit a preauthorization request?","Question",{"text":108,"@type":109},"Providers should complete this form and submit it alongside supporting documentation, keeping all original records for their files.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is the criteria for an urgent request?",{"text":113,"@type":109},"Only situations involving life-threatening conditions will be considered for urgent preauthorization request processing.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed preauthorization form be sent?",{"text":117,"@type":109},"The form can be faxed to 1-866-311-9603 or mailed to the Provider Inquiry, Preapproval department in Detroit, MI.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287771,1790186583,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Blue Cross Blue Shield of Michigan Request for Preauthorization Form  \nMost preauthorization requests can be resolved by contacting Provider Relations and Servicing, or PRS, and requesting member benefits. However, if you would like to submit a request for preauthorization after contacting PRS, you may submit a written request by completing this form. Include any documents to support your request, send a copy of your documents and keep all originals. Please only submit one preauthorization per form.  \n☐ Urgent Request  \n☐ Non-urgent Request  \nOnly life-threatening situations will be considered for urgent requests.  \n\n| Provider Information |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Provider’s Name |  | Requesting Provider NPI/PIN |  | Provider Telephone Number |  |\n| Address | City |  | State |  | Zip Code |\n| Contact Name |  | Contact Telephone Number |  | Contact Fax Number |  |\n\n\n| Enrollee/Patient Information |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Enrollee’s Name | Date of Birth |  | Enrollee ID |  | Group Number |\n| Patient’s Name |  | Patient’s Date of Birth |  | Daytime Telephone Number |  |\n| Address | City |  | State |  | Zip Code |\n\n\n| Preauthorization Section |  |\n| --- | --- |\n| Procedure/HCPCS Codes | ICD-10 Diagnosis Codes |\n| Preauthorization Description |  |\n\nFax: 1-866-311-9603  \nProvider Inquiry, Preapproval – Mail Code 0450 Blue Cross Blue Shield of Michigan  \nP.O. Box 2227  \nDetroit, MI 48231-2227","cbCaicfcHpYK8NPR","https://ap.wps.com/l/cbCaicfcHpYK8NPR","pdf",191315,"English","# Request for Preauthorization Form\n## Provider Information\n## Enrollee-Patient Information\n## Preauthorization Section","[{\"question\":\"How should medical providers submit a preauthorization request?\",\"answer\":\"Providers should complete this form and submit it alongside supporting documentation, keeping all original records for their files.\"},{\"question\":\"What is the criteria for an urgent request?\",\"answer\":\"Only situations involving life-threatening conditions will be considered for urgent preauthorization request processing.\"},{\"question\":\"Where should the completed preauthorization form be sent?\",\"answer\":\"The form can be faxed to 1-866-311-9603 or mailed to the Provider Inquiry, Preapproval department in Detroit, MI.\"}]","Blue Cross Blue Shield of Michigan Request for Preauthorization Form | PDF",1789632713]