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It covers key clinical categories such as behavioral health, inpatient admissions, transplants, medical benefit drugs, prescription drugs, advanced imaging, and multiple other services. Definitions explain prior authorization and e-referral workflows, including provider obligations to submit requests and supporting clinical documentation.",{"@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":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/preauthorization-and-precertification-requirements/288818/",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/preauthorization-and-precertification-requirements/288818.png","ImageObject",442,249,{"name":88,"@type":89},"Gelato","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},"What is prior authorization, and why is it required?","Question",{"text":108,"@type":109},"Prior authorization is a process where Blue Cross Blue Shield of Michigan requires prior authorization for certain procedures to ensure members receive the right care at the right time and in the right location. Providers must submit requests before services are provided.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What do health care providers need to submit with a prior authorization request?",{"text":113,"@type":109},"For some procedures or services, providers must submit clinical documentation explaining why the proposed procedure or service is medically necessary.",{"name":115,"@type":106,"acceptedAnswer":116},"Which member programs does the document cover?",{"text":117,"@type":109},"It addresses prior authorization requirements for Blue Cross commercial products and Medicare Plus Blue members, including related categories and services listed throughout the document.","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},288818,1790191364,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":50,"category_name":51,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},19241457091524,"https://us-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","In this document  \nDefinitions .................................................................................................................................................. 3  \nDetermining whether procedure codes require prior authorization for a member ...................................... 3  \nBehavioral health ........................................................................................................................................ 4  \nBlue Cross commercial products and Medicare Plus Blue℠ ................................................................... 4  \nHuman organ transplants ........................................................................................................................... 6  \nBlue Cross commercial products (non-Medicare) ................................................................................... 6  \nMedicare Plus Blue ................................................................................................................................ 7  \nInpatient admissions ................................................................................................................................... 7  \nBlue Cross commercial products (non-Medicare) ................................................................................... 7  \nMedicare Plus Blue .............................................................................................................................. 10  \nMedical benefit drugs ............................................................................................................................... 11  \nBlue Cross commercial products and Medicare Plus Blue ................................................................... 11  \nOther medical/surgical procedures ........................................................................................................... 12  \nMedicare Plus Blue .............................................................................................................................. 12  \nPrescription drugs .................................................................................................................................... 12  \nBlue Cross commercial products (non-Medicare) ................................................................................. 12  \nMedicare Plus Blue and Prescription BlueSM PDP................................................................................ 13  \nAdvanced imaging and cardiology services ............................................................................................. 13  \nBlue Cross commercial products (non-Medicare) ................................................................................. 13  \nMedicare Plus Blue .............................................................................................................................. 13  \nIn-lab sleep studies and implantation of hypoglossal nerve stimulation devices ..................................... 14  \nBlue Cross commercial products (non-Medicare) ................................................................................ 14  \nAir ambulance .......................................................................................................................................... 15  \nBlue Cross commercial products (non-Medicare) ................................................................................. 15  \nMedicare Plus Blue .............................................................................................................................. 15  \nPrivate duty nursing.................................................................................................................................. 15  \nBlue Cross commercial products (non-Medicare) ................................................................................. 15  \nHome health care.........................................................................................................","cbCaikb9k6P3mi5T","https://ap.wps.com/l/cbCaikb9k6P3mi5T","pdf",455521,20,"English","# Determining whether procedure codes require prior authorization for a member\n## Behavioral health\n## Blue Cross commercial products and Medicare Plus Blue℠\n## Human organ transplants\n## Blue Cross commercial products (non-Medicare)\n## Medicare Plus Blue\n## Inpatient admissions\n## Medical benefit drugs\n## Other medical/surgical procedures\n## Prescription drugs\n## Advanced imaging and cardiology services\n## In-lab sleep studies and implantation of hypoglossal nerve stimulation devices\n## Air ambulance\n## Private duty nursing\n## Home health care\n## Other services\n## Musculoskeletal and pain management procedures\n## Continuous glucose monitor products\n## Durable medical equipment, prosthetics and orthotics, including diabetes supplies\n## Radiation oncology, including proton beam therapy","[{\"question\":\"What is prior authorization, and why is it required?\",\"answer\":\"Prior authorization is a process where Blue Cross Blue Shield of Michigan requires prior authorization for certain procedures to ensure members receive the right care at the right time and in the right location. Providers must submit requests before services are provided.\"},{\"question\":\"What do health care providers need to submit with a prior authorization request?\",\"answer\":\"For some procedures or services, providers must submit clinical documentation explaining why the proposed procedure or service is medically necessary.\"},{\"question\":\"Which member programs does the document cover?\",\"answer\":\"It addresses prior authorization requirements for Blue Cross commercial products and Medicare Plus Blue members, including related categories and services listed throughout the document.\"}]","Preauthorization and Precertification Requirements | PDF",1789634011,7]