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Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral / Clinical Review Program
Guidelines related to plan notification, clinical review and referral requirements
for members with all BCN HMOSM, BCN AdvantageSM HMO-POS and BCN AdvantageSM HMO products
For more complete information about plan notification, clinical review and referral requirements, refer to the BCN Provider Manual.
BCN Care Management Hours:
Monday through Thursday 8:30 a.m. to 12 noon and 1 p.m. to 5 p.m.
Friday 9:30 a.m. to 12 noon and 1 p.m. to 5 p.m.
Telephone: 1-800-392-2512
BCN Behavioral Health Hours:
Monday through Friday 8 a.m. to 5 p.m.
Telephone – BCN: 1-800-482-5982
Telephone – BCN Advantage: 1-800-431-1059
OUT-OF-STATE SERVICES: Clinical review and referral requirements for out-of-state services may vary from those outlined in this document.
For information on requirements for out-of-state services, contact BCN Care Management at 1-800-392-2512.
For all services, noncontracted providers and providers who are not part of the designated network associated
with the member's plan must obtain clinical review from BCN Care Management.
Section 1: Plan notification and clinical review requirements Plan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical reviews on services
that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical review is conducted for
benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at least 14 days prior
to services being rendered. Note: This list is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service by
BCN Care Management based on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may be
subject to edits including, but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.
Service
Requirements
Adagen® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Aldurazyme® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Aralast NP §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Arthroscopy, knee
Benefit / clinical review is required for all members. Must complete the appropriate knee arthroscopy
questionnaire.
Autism treatment: applied behavior analysis
Contact BCN Behavioral Health for benefit / clinical review. Evaluation at a Blues-approved autism
evaluation center is required, with BCN notified prior to the evaluation. Does not apply to members
with BCN Advantage products. For additional information, see Autism services.
Autism treatment: PT-OT-ST services
See entry for physical / occupational / speech therapy in this section.
Bariatric surgery
Benefit / clinical review is required for all members.
Benlysta® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Berinert® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Biofeedback for urinary incontinence and
chronic constipation
Benefit / clinical review is required for all members.
Bone anchored hearing aid
Benefit / clinical review is required for all members.
Boniva §
Prior authorization / clinical review is required for all members.
Botox® §
Prior authorization / clinical review is required for all members.
Breast biopsy, excisional
Benefit / clinical review is required for all members. Must complete the breast biopsy (excisional)
questionnaire.
Cardiac rehabilitation
Benefit / clinical review is required for all members.
Cerezyme §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Chiropractic services
Plan notification is required for all members, including those whose coverage allows self-referrals.
CinryzeTM §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Cognitive therapy
Benefit / clinical review is required for all members.
Colonoscopy – virtual
Benefit / clinical review is required for all members.
Coronary computed tomographyangiography (CCTA)
Effective Feb. 3, 2014: Benefit / clinical review is required for all members. Must complete the CCTA
questionnaire.
Cosmetic surgery
Benefit / clinical review is required for all members.
Dental services
Benefit / clinical review is required for all members.
®
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Page 1 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
For all services, noncontracted providers and providers who are not part of the designated network associated
with the member's plan must obtain clinical review from BCN Care Management.
Section 1: Plan notification and clinical review requirements Plan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical reviews on services
that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical review is conducted for
benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at least 14 days prior
to services being rendered. Note: This list is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service by
BCN Care Management based on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may be
subject to edits including, but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.
Service
Requirements
Developmental delay treatment
Benefit / clinical review is required for all members.
Diagnostic and therapeutic tests
A global referral is required for HMO members in the East and Southeast regions; for all other
members, including HMO members in the Mid, West and Upper Peninsula regions, no plan
notification or benefit / clinical review is required. No plan notification or benefit / clinical review is
required for members with BCN Advantage HMO-POS.
Note: For University of Michigan Premier Care, Premier Care 65 and GradCare members, and for
members with Blue Cross® Metro Detroit HMO, Blue Cross® Partnered, BCN AdvantageSM HMO
ConnectedCare and BCN AdvantageSM HMO MyChoice Wellness coverage, see exceptions to the
general rule in Section 2: Referral requirements.
DME, medical supplies – diabetic supplies
only (includes diabetic shoes / inserts)
Benefit / clinical review is required for all members. Must contact J & B Medical Supply to review all
requests for diabetic and insulin pump supplies and diabetic shoes / inserts (1-888-896-6233).
DME, medical supplies, P&O – nondiabetic
Benefit / clinical review is required for all members. Must contact Northwood to review all requests
for nondiabetic DME, medical supplies and prosthetics / orthotics (1-800-667-8496).
Elaprase® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Elective termination of pregnancy
Benefit / clinical review is required for all members.
Electrocardiographic rhythm recording and
storage devices, long-term, continuous
(such as the Zio® Patch and LifeStar ACT)
Benefit / clinical review is required for all members.
Electroconvulsive therapy
Benefit / clinical review is required for all members.
Elelyso
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
TM
§
Endometrial ablation (in office only)
Benefit / clinical review is required for all members. Must complete the endometrial ablation
questionnaire.
Experimental and investigational
Benefit / clinical review is required for all members.
Eylea §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Fabrazyme® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Firazyr® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Flolan® §
Prior authorization / clinical review is required for all members.
Fusilev® (levoleucovorin) §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Glassia §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Home health care
Benefit / clinical review is required for UAW Retiree Medical Benefits Trust members. For all other
members, no plan notification or benefit / clinical review is required.
Home TPN and enteral feedings
Benefit / clinical review is required for all members.
H.P. Acthar Gel §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Hyperbaric oxygen therapy
Benefit / clinical review is required for all members.
Ilaris® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Immune globulin therapy (IV / SQ) §
Prior authorization / clinical review is required for all members.
Infertility procedures
Benefit / clinical review is required for all members.
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Page 2 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
For all services, noncontracted providers and providers who are not part of the designated network associated
with the member's plan must obtain clinical review from BCN Care Management.
Section 1: Plan notification and clinical review requirements Plan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical reviews on services
that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical review is conducted for
benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at least 14 days prior
to services being rendered. Note: This list is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service by
BCN Care Management based on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may be
subject to edits including, but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.
Service
Requirements
Inpatient admissions
Benefit / clinical review is required for all members. This includes for long-term acute care, inpatient
rehabilitation and skilled nursing care. Providers should notify BCN of all emergency admissions
within 1 business day.
Intensive outpatient therapy (mental health
/ substance abuse)
Benefit / clinical review is required for all members.
Jevtana® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Kadcyla® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Kalbitor® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
KrystexxaTM §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Kyprolis® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Laboratory services, genetic tests
Benefit / clinical review is required for all members. Must send requests to JVHL at 1-800-445-4979.
Lucentis® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Lumizyme® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
MakenaTM §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Maternity: up to 48 hours following routine
delivery / 96 hours following C-section
Plan notification is required for all members, including those whose coverage allows self-referrals.
Mental health therapy
Benefit / clinical review is required for all members through BCN Behavioral Health.
MRI of breast
Benefit / clinical review is required for all members.
Myozyme §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Naglazyme® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Neuropsychological / psychological testing
for bariatric surgery
Plan notification is required for all members.
Nplate® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Orthognathic surgery
Benefit / clinical review is required for all members.
Pain management with epidural or facet
joint injections
Benefit / clinical review is required for all members. Must complete the appropriate pain management
questionnaire.
Partial hospitalization (mental health /
substance abuse)
Benefit / clinical review is required for all members.
Physical / occupational / speech therapy autism treatment
The provider is responsible for verifying whether each member has autism benefits and, if so,
how they are managed and what the clinical review requirements are. In general, benefit / clinical
review is not required for members whose autism benefits are managed separate from their
medical benefits. It may be required for members whose autism benefits are managed as part of
their medical benefits. When clinical review is required, those requests are handled by BCN Care
Management. Refer to the e-referral Autism page for additional information.
Physical / occupational / speech therapy unrelated to autism treatment
Benefit / clinical review is required for all members. Contact Landmark Healthcare and see additional
information on Outpatient PT-OT-ST Management Program.
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Page 3 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
For all services, noncontracted providers and providers who are not part of the designated network associated
with the member's plan must obtain clinical review from BCN Care Management.
Section 1: Plan notification and clinical review requirements Plan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical reviews on services
that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical review is conducted for
benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at least 14 days prior
to services being rendered. Note: This list is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service by
BCN Care Management based on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may be
subject to edits including, but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.
Service
Requirements
®
Prolastin §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
ProliaTM §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Proton beam therapy
Benefit / clinical review is required for all members.
Provenge §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Pulmonary rehabilitation
Benefit / clinical review is required for all members.
Radiology high-tech procedures
All BCN-participating freestanding diagnostic facilities, outpatient hospital settings, ambulatory
surgery centers and physician’s offices that provide MRI, CT, nuclear medicine and nuclear
cardiology are required to call 1-855-774-1317 or to visit www.carecorenational.com (starting July 6,
2015, visit www.evicore.com) for clinical review. Refer to BCN's e-referral Radiology Management
Program Web page for additional information.
Reclast®
See zoledronic acid.
®
Remodulin §
Prior authorization / clinical review is required for all members.
Sleep studies
Benefit / clinical review is required for all members. Must complete a questionnaire for the Sleep
Management Program. In addition, effective Aug. 5, 2013, a nondiagnostic home sleep test is
required for adult members with symptoms of obstructive sleep apnea without certain other comorbid
conditions prior to consideration for coverage of a sleep study in the outpatient facility or clinic.
Soliris® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Specialist office visits and treatment
A global referral is required for HMO members in the East and Southeast regions; for all other
members, including HMO members in the Mid, West and Upper Peninsula regions, no plan
notification or benefit / clinical review is required. No plan notification or benefit / clinical review is
required for members with BCN Advantage HMO-POS.
®
Note: For University of Michigan Premier Care, Premier Care 65 and GradCare members, and
for members with Blue Cross Metro Detroit HMO, Blue Cross Partnered, BCN Advantage HMO
ConnectedCare and BCN Advantage HMO MyChoice Wellness coverage, see exceptions to the
general rule in Section 2: Referral requirements.
Spine Care Referral Program
Benefit / clinical review is required for all members for the initial visit to a spine care specialist and for
office visits / procedures. This includes members with coverage through products that would typically
allow for self-referral within a designated provider network. See additional information on the Spine
Care Referral Program.
StelaraTM §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Substance abuse therapy
Benefit / clinical review is required for all members through BCN Behavioral Health.
Surgery, lumbar spine
Benefit / clinical review is required for all members. Must complete the appropriate lumbar spine
surgery questionnaire.
Surgical procedures, routine
A global referral is required for HMO members in the East and Southeast regions; for all other
members, including HMO members in the Mid, West and Upper Peninsula regions, no plan
notification or benefit / clinical review is required. No plan notification or benefit / clinical review is
required for members with BCN Advantage HMO-POS.
Note: For University of Michigan Premier Care, Premier Care 65 and GradCare members, and
for members with Blue Cross Metro Detroit HMO, Blue Cross Partnered, BCN Advantage HMO
ConnectedCare and BCN Advantage HMO MyChoice Wellness coverage, see exceptions to the
general rule in Section 2: Referral requirements.
TMJ treatment
Benefit / clinical review is required for all members.
Transcatheter aortic valve implantation
(TAVI) and replacement (TAVR)
Benefit / clinical review is required for all members effective July 1, 2013.
Page 4 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
For all services, noncontracted providers and providers who are not part of the designated network associated
with the member's plan must obtain clinical review from BCN Care Management.
Section 1: Plan notification and clinical review requirements Plan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical reviews on services
that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical review is conducted for
benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at least 14 days prior
to services being rendered. Note: This list is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service by
BCN Care Management based on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may be
subject to edits including, but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.
Service
Requirements
Transcranial magnetic stimulation (TMS)
for psychiatric or neurological disorders
Benefit / clinical review is required for all members effective Oct. 1, 2013.
Transgender surgery
Benefit / clinical review is required for all members.
Transplants
Benefit / clinical review is required for all members, for solid organ and bone marrow evaluations and
harvesting (except kidney / skin / cornea):
• HMO members should be directed to a Blue Distinction® Center+ for Transplants if one is available
for the type of transplant the member needs. If one is not available, a Blue Distinction® Center for
Transplants facility may be used. This is effective May 1, 2015.
• BCN Advantage members must have their transplants performed in a CMS-approved facility
that is contracted with BCN. When a Blue Distinction Center for Transplants is available, BCN
Advantage members should be referred there.
Unclassified procedures
Benefit / clinical review is required for all members. (Also called "not otherwise classified (NOC),"
"unlisted" and "unspecified.")
Varicose veins, treatment
Benefit / clinical review is required for all members. Must complete the varicose vein treatment
questionnaire.
Ventricular assistive devices, percutaneous
Benefit / clinical review is required for all members.
Vpriv §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Woman’s Choice services
See Woman's Choice Referral and Clinical Review Guidelines.
XgevaTM §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Xiaflex® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Yervoy® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Zemaira® §
Prior authorization / clinical review is required for all members except those with BCN Advantage
coverage.
Zoledronic acid (Reclast® or Zometa® ) §
Prior authorization / clinical review is required for all members. Must complete the zoledronic acid
questionnaire.
Zometa®
See zoledronic acid.
®
§ See the footnote on page 9.
Note: BCN 65 members: BCN Care Management must be notified before a member’s Medicare days are exhausted. Infusion is not routinely covered
by Medicare. All care should be coordinated by the primary care physician.
Note: BCN as secondary carrier: BCN does not require clinical review when it is the secondary payer. However, the claim will be denied when the
service is not a BCN covered benefit and the member has not followed the requirements of the primary carrier.
Page 5 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
Section 2: Referral requirements GENERAL RULE. When members need specialty care, their primary care physician must submit a global referral to BCN for a contracted provider.
A global referral allows the specialist to perform necessary services to diagnose and treat a member in the office, with the exception of services that
require benefit / clinical review. Specialists may not refer patients to other specialists. If the specialist determines services are needed outside those
specified by a global referral, including further diagnosis or treatment in an alternate treatment setting (either outpatient or inpatient), the specialist is
responsible for submitting all required plan notifications or clinical review requests to BCN.
EXCEPTIONS TO THE GENERAL RULE. The following are exceptions to the requirement for a global referral.
• Global referrals cannot be used for chiropractic services or for physical, occupational or speech therapy; see Section 1 for those requirements.
• BCN’s referral requirements vary based on the region assigned to the medical care group the member’s primary care physician is associated with.
(See the Blue Care Network Provider Consultant Regions map at the end of this document.) For BCN HMO members not assigned to a U-M primary
care physician and living in the Mid, West or Upper Peninsula region, no global referral is required as long as the specialist is located in one of those
regions. For BCN HMO members not assigned to a U-M primary care physician and living in the East or Southeast region, a referral is required.
• For University of Michigan Premier Care, Premier Care 65 and GradCare members assigned to a non-U-M primary care physician and referred to any
specialist (U-M or non-U-M), a referral is required. This guideline applies regardless of where the member lives or where the practitioners are located.
• For BCN Advantage HMO-POS members in any region, no global referral is required as long as the specialist is part of the BCN Advantage HMO-POS
network.
• For Blue Cross Partnered, BCN Advantage HMO ConnectedCare and BCN Advantage MyChoice Wellness members, services rendered by providers
outside of the network designated for each of those products require clinical review.
• Blue Cross Metro Detroit HMO members must choose their primary care physician from within the Blue Cross Metro Detroit HMO provider network.
That physician coordinates services within the Blue Cross Metro Detroit HMO provider network. Standard referral and clinical review requirements
apply.
• Members who have coverage through Blue Elect Plus Self-Referral OptionSM may choose to self-refer to any provider within or outside of the statewide
BCN HMO network provider without need for a referral, but clinical review requirements do apply for certain services and some services are covered
only if rendered by an in-network provider. Providers should go to web-DENIS to get full information on the requirements for each service.
• For members who have coverage through self-funded or other products that allow members to refer themselves directly to a specialist within a
designated provider network, no referral is required from the primary care physician in order to access specialist services within that network. However,
benefit/clinical review requirements apply. Providers should always check Section 1 of this document for benefit/clinical review requirements.
• Some services do not require a referral as long as the service is performed by a contracted provider. The table below provides a list of services that do
not require a referral for ANY member. Note: This list is not all-inclusive.
Note: When a referral does not need to be submitted to BCN, the primary care physician can "refer" the member to the specialist using any method that
can be documented by both the primary care physician and the specialist -- for example, a written request, fax or prescription, or telephone notes.
Office / outpatient / ancillary services
Ambulance - emergent
Referral is not required for any member.
Anesthesia
Referral is not required for any member.
Bone density studies
Referral is not required for any member.
Cardiac stress tests
Referral is not required for any member.
Chemotherapy / radiation
Referral is not required for any member.
Diagnostic and therapeutic tests
See Section 1.
Echocardiograms
Referral is not required for any member.
EKGs
Referral is not required for any member.
Emergency room services
Referral is not required for any member.
Fetal non-stress tests
Referral is not required for any member.
Hearing aid services (with hearing aid rider)
Referral is not required for any member.
Holter monitor
Referral is not required for any member.
Home health care
See Section 1.
Home infusion
Referral is not required for any member.
Immunizations
Referral is not required for any member.
Laboratory services, general
Referral is not required for any member.
Neuropsychological / psychological testing for other than bariatric surgery
Referral is not required for any member.
Observation stays
Referral is not required for any member.
Note: Surgical procedures rendered during an observation stay
require a separate outpatient referral, plan notification or benefit/
clinical review. For the benefit/clinical review requirements
pertaining to other procedures rendered during observation, see
Section 1.
Page 6 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
Section 2: Referral requirements GENERAL RULE. When members need specialty care, their primary care physician must submit a global referral to BCN for a contracted provider.
A global referral allows the specialist to perform necessary services to diagnose and treat a member in the office, with the exception of services that
require benefit / clinical review. Specialists may not refer patients to other specialists. If the specialist determines services are needed outside those
specified by a global referral, including further diagnosis or treatment in an alternate treatment setting (either outpatient or inpatient), the specialist is
responsible for submitting all required plan notifications or clinical review requests to BCN.
EXCEPTIONS TO THE GENERAL RULE. The following are exceptions to the requirement for a global referral.
• Global referrals cannot be used for chiropractic services or for physical, occupational or speech therapy; see Section 1 for those requirements.
• BCN’s referral requirements vary based on the region assigned to the medical care group the member’s primary care physician is associated with.
(See the Blue Care Network Provider Consultant Regions map at the end of this document.) For BCN HMO members not assigned to a U-M primary
care physician and living in the Mid, West or Upper Peninsula region, no global referral is required as long as the specialist is located in one of those
regions. For BCN HMO members not assigned to a U-M primary care physician and living in the East or Southeast region, a referral is required.
• For University of Michigan Premier Care, Premier Care 65 and GradCare members assigned to a non-U-M primary care physician and referred to any
specialist (U-M or non-U-M), a referral is required. This guideline applies regardless of where the member lives or where the practitioners are located.
• For BCN Advantage HMO-POS members in any region, no global referral is required as long as the specialist is part of the BCN Advantage HMO-POS
network.
• For Blue Cross Partnered, BCN Advantage HMO ConnectedCare and BCN Advantage MyChoice Wellness members, services rendered by providers
outside of the network designated for each of those products require clinical review.
• Blue Cross Metro Detroit HMO members must choose their primary care physician from within the Blue Cross Metro Detroit HMO provider network.
That physician coordinates services within the Blue Cross Metro Detroit HMO provider network. Standard referral and clinical review requirements
apply.
• Members who have coverage through Blue Elect Plus Self-Referral Option may choose to self-refer to any provider within or outside of the statewide
BCN HMO network provider without need for a referral, but clinical review requirements do apply for certain services and some services are covered
only if rendered by an in-network provider. Providers should go to web-DENIS to get full information on the requirements for each service.
• For members who have coverage through self-funded or other products that allow members to refer themselves directly to a specialist within a
designated provider network, no referral is required from the primary care physician in order to access specialist services within that network. However,
benefit/clinical review requirements apply. Providers should always check Section 1 of this document for benefit/clinical review requirements.
• Some services do not require a referral as long as the service is performed by a contracted provider. The table below provides a list of services that do
not require a referral for ANY member. Note: This list is not all-inclusive.
Note: When a referral does not need to be submitted to BCN, the primary care physician can "refer" the member to the specialist using any method that
can be documented by both the primary care physician and the specialist -- for example, a written request, fax or prescription, or telephone notes.
Office / outpatient / ancillary services
Pacemaker adjustments
Referral is not required for any member.
Pediatric Choice services
See BCN Requirements for Pediatric Choice Program.
Radiology - routine (procedure codes other than those identified as high-tech)
Referral is not required for any member. Also see Section 1.
Specialist office visits and treatment
See Section 1.
Sterilization procedures (with appropriate benefit)
Referral is not required for any member.
Surgical procedures, routine
See Section 1.
Urgent care
Referral is not required for any member.
Woman's Choice services
See Woman's Choice Referral and Clinical Review Guidelines.
VENDOR CONTACT INFORMATION
Vendor name
Services
Contact information
eviCore healthcare
Reviews requests for select high-tech radiology procedures.
www.evicore.com
1-855-774-1317
J&B Medical Supply
Reviews all requests for outpatient diabetic and insulin pump supplies
1-888-896-6233
JVHL
Provides statewide network and third-party administration for outpatient laboratory services
1-800-445-4979
Landmark Healthcare
Provides care management for members receiving physical, occupational and speech therapy
services in office and outpatient settings, including outpatient hospital settings
LMhealthcare.com
Northwood
Reviews all requests for outpatient nondiabetic DME, medical supplies and P&O
1-800-667-8496
Page 7 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
SEC. 3: For services not involving medications covered under the medical benefit
Procedures That Require Clinical Review
Procedure codes* (Note: This list is not all inclusive.)
Note: ALL procedures with "not otherwise classified (NOC)," "unclassified," "unlisted" or "unspecified" codes require clinical review.
00170
19340
2120821210
29870
4084240845
58260
6447964480
74160 ¶
9086790869
97116
S0199
0295T0298T
19342
21215
2987329877
41800
58275
6448364484
74170 ¶
90901
97124
S2083
0318T
19350
21230
2987929883
4180541806
58291
6449064495
7417674178 ¶
90911
97140
S2202
1192011922
19355
21235
2988529887
4182041823
58353
6790067909
7418174183 ¶
9250792508
97150
S9472S9473
1578015783
19357
21240
30400
4182541828
58356
6971069718
74263
9252192524
97530
1578615789
19361
2124221249
30410
41830
5854158544
70328
7557175574
9379793798
9753297533
1579215793
19364
21255
30420
41850
58550
70336
77003
9578295783
97535
1581915830
1936619371
21270
30430
41870
5855258554
70450 ¶
7705877059
9580095801
97537
1583215839
19380
21280
30435
41872
58563
70460 ¶
77520
9580595811
97542
15847
19396
21282
30450
41874
5984059841
70470 ¶
7752277523
96105
9754597546
1587615879
21010
2129521296
30620
42120
5985059852
7048670488 ¶
77525
9700197004
97750
17340
21050
21480
3166031661
4364443645
5985559857
7055170553 ¶
7820178202 ¶
97010
97755
17360
21060
21485
3336133369
4377043775
6228162282
71250 ¶
7820578206 ¶
97012
99183
17380
21070
21490
3399033993
4384243848
62287
71260 ¶
7821578216 ¶
97014
A4575
19101
21116
2149321494
3646836471
4388643888
6231062311
71270 ¶
7822678227 ¶
97016
C1300
19120
2112021127
22533
3647536476
44130
6231862319
7213172133 ¶
7845178454 ¶
97018
G0289
1912519126
2114121147
22558
3647836479
55970
63005
7214172142 ¶
78466 ¶
97022
G0398G0400
19300
2115021151
22612
37718
55980
63012
7214672149 ¶
7846878469 ¶
97024
G0422G0424
19316
2115421155
22630
37722
56805
63017
7215672158 ¶
7847278473 ¶
97026
L8039
19318
2115921160
2733227333
3776537766
57335
63030
7219272194 ¶
78481 ¶
97028
L8600
1932419325
21188
27425
37780
58150
63042
7321873223 ¶
78483 ¶
9703297036
L8692
19328
2119321199
29800
37785
58152
63047
7371873723 ¶
78494 ¶
97110
Q4100
19330
21206
29804
40840
58180
63056
74150 ¶
78496 ¶
9711297113
S0190S0191
*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
¶ Effective July 1, 2014, clinical review requests for these procedures must be reviewed by eviCore healthcare (formerly CareCore National). Refer to
BCN's e-referral Radiology Management Program Web page for information on the eviCore review process.
Note: Additional details are provided about the services represented by these codes in the tables found earlier in this document.
Page 8 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
SEC. 4: For services involving medications covered under the medical benefit
Procedures That Require Clinical Review §
Procedure codes (Note: This list is not all inclusive.)
Note: ALL procedures with "not otherwise classified (NOC)," "unclassified," "unlisted" or "unspecified" codes require clinical review.
C9269C9270
J0220J0221
J0638
J1290
J1559
J1725
J2504
J3285
J3590
J9999
C9272C9273
J0256J0257
J0641
J1300
J1561
J1740
J2507
J3357
J9043
Q2040
J0178
J0490
J0775
J1325
J1566
J1743J1744
J2778
J3385
J9047
Q2042Q2044
J0180
J0585J0588
J0800
J1458J1459
J1568J1569
J1786
J2796
J3489
J9228
J0215
J0597J0598
J0897
J1557
J1572
J1931
J3060
J3490
J9354
§ For medications covered under the medical benefit that require prior authorization / clinical review, providers are encouraged to submit requests
using the e-referral system by including the necessary information in the e-referral Comments section. The requests may also be called in to BCN
Care Management at 1-800-392-2512 or submitted using the Medical Benefit Drug Request Form. This form can be accessed on the e-referral
Forms Web page. In addition, see Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review, which
shows the clinical information and criteria for each drug.
Note: Additional details are provided about the services represented by these codes in the tables found earlier in this document.
Page 9 of 11
Revised July 1, 2015
Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.
2015 BCN Referral and Clinical Review Program
Blue Dot Changes to the
2015 BCN Referral and Clinical Review Program Service or
Topic
Change Description
Radiology
management
CareCore National is renamed eviCore healthcare. Starting July 6, 2015, to submit online requests for clinical review for
high-tech radiology procedures, providers should visit www.evicore.com. Until that date, providers should visit
www.carecorenational.com.
Drugs covered under
the medical benefit
that require prior
authorization / clinical
review
Effective July 1, 2015, services associated with the drugs listed below require prior authorization / clinical review for all
members except those with BCN Advantage coverage.
Transplants
The requirements for transplants are clarified:
• Adagen
• Firzyr
• Kadcyla
• Lumizyme
• Naglazyme
• Aldurazyme
• Jevtana
• Kyprolis
• Myozyme
• Xiaflex
• Yervoy
• HMO members should be directed to a Blue Distinction Center+ for Transplants if one is available for the type of
transplant the member needs. If one is not available, a Blue Distinction Center for Transplants facility may be used.
This is effective May 1, 2015.
• BCN Advantage members must have their transplants performed in a CMS-approved facility that is contracted with
BCN. When a Blue Distinction Center for Transplants is available, BCN Advantage members should be referred there.
Drugs covered under
the medical benefit
that require prior
authorization / clinical
review
Effective April 1, 2015, services associated with the drugs listed below require prior authorization / clinical review for all
members except those with BCN Advantage coverage.
• Aralast NP
• Elaprase
• Fabrazyme
• Ilaris
• Soliris
• Cerezyme
• Elelyso
• Glassia
• Prolastin
• Vpriv
• Zemaira
For services associated with procedure code J9999, all requests require prior authorization / clinical review for all
members, effective April 1, 2015.
The list of procedure codes that require clinical review is now divided into two lists: one for services not involving drugs
covered under the medical benefit (titled "Sec. 3") and the other for services involving drugs covered under the medical
benefit (titled "Sec. 4").
BCN Advantage HMO
ConnectedCare
References to BCN Advantage HMO Local are removed. Information about BCN Advantage HMO ConnectedCare is
added. This product is effective Jan. 1, 2015, and has its own designated provider network. For BCN Advantage HMO
ConnectedCare members, services rendered by providers outside of the network designated for that product require
clinical review.
Blue Cross Metro Detroit
HMO
Information about to the Blue Cross Metro Detroit HMO product is added. The Blue Cross Metro Detroit HMO product,
which is effective Jan. 1, 2015, has its own designated provider network. Standard referral and clinical review
requirements apply.
Blue Elect Plus SelfReferral Option
The information about Blue Elect Plus Self-Referral Option requirements is clarified. Members who have coverage through
Blue Elect Plus Self-Referral Option may choose to self-refer to any provider within or outside of the statewide BCN HMO
network provider without need for a referral, but clinical review requirements do apply for certain services and some
services are covered only if rendered by an in-network provider. Providers should go to web-DENIS to get full information
on the requirements for each service.
Radiology high-tech
procedures
The requirements for high-tech radiology procedures are clarifed. All BCN-participating freestanding diagnostic facilities,
outpatient hospital settings, ambulatory surgery centers and physician’s offices that provide MRI, CT, nuclear medicine
and nuclear cardiology are required to call 1-855-774-1317 or to visit www.carecorenational.com (starting July 6, 2015,
visit www.evicore.com) for clinical review. Refer to BCN's e-referral Radiology Management Program Web page for
additional information.
Page 10 of 11
Revised July 1, 2015
Blue Cross Blue Shield of Michigan
and Blue Care Network
bcbsm.com
Provider Consultant Regions
Keweenaw
Houghton
Ontonagon
Baraga
Gogebic
Luce
Marquette
Alger
Iron
Dickinson
Chippewa
Schoolcraft
Mackinac
Delta
Menominee
Upper Peninsula
Emmet
Cheboygan
Presque
Isle
Charlevoix
Antrim
West region
Otsego
Montmorency
Alpena
Crawford
Oscoda
Alcona
East region
Leelanau
Provider consultant
regional toll-free numbers:
Upper Peninsula
1-866-497-7647
West Michigan
1-800-968-2583
East Michigan
1-800-527-1906
Mid region
Grand
Traverse
Benzie
Kalkaska
Southeast region
Manistee
Mason
Wexford
Missaukee Roscommon
Osceola
Lake
Clare
Iosco
Ogemaw
Arenac
Gladwin
Huron
Oceana
Newaygo
Mecosta
Isabella
Mid Michigan
1-877-258-0168
Allegan
Southeast
1-866-299-4667
Van Buren
Berrien
Cass
Ionia
Eaton
Barry
Kalamazoo
Clinton
Calhoun
St. Joseph Branch
Sanilac
Saginaw
Gratiot
Muskegon
Kent
Bay
Tuscola
Montcalm
Ottawa
Midland
Shiawassee
Ingham
Jackson
Hillsdale
Genesee
Livingston
Oakland
Washtenaw
Lenawee
Lapeer
St. Clair
Macomb
Wayne
Monroe
Here’s how to find more comprehensive contact information:
1
Log in at bcbsm.com/provider. 2 Click on web-DENIS.
Updated June 2014
3
Click either BCBSM Contact Us or
BCN Contact Us.
R011579