Transcription of Provider Preauthorization and Precertification Requirements
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Provider Preauthorization and Precertification Requirements
Provider Preauthorization and Precertification Requirements For Blue Cross PPO (commercial) and Medicare Plus BlueSM PPO members Revised Nov. 29, 2021 SPECIAL NOTE: Clinical review Requirements temporarily suspended for admissions to skilled nursing facilities from hospitals in certain states. See Section 4: Inpatient Admissions for more information. Table of Contents 1. Blue Cross Blue Shield of Michigan Definitions .. 2 2. Behavioral Health .. 2 Blue Cross Blue Shield of Michigan Commercial Products (Non-Medicare) .. 2 Medicare Plus BlueSM PPO .. 3 3. Human Organ Transplants .. 4 Blue Cross Blue Shield of Michigan Commercial Products (Non-Medicare) .. 4 Medicare Plus BlueSM PPO .. 4 4. Inpatient Admissions .. 5 Blue Cross Blue Shield of Michigan Commercial Products (Non-Medicare) .. 5 Medicare Plus BlueSM PPO .. 8 5. Medical Benefit Drugs .. 11 Blue Cross Blue Shield of Michigan PPO (commercial) and Medicare Plus BlueSM PPO Products .. 11 6. Other Medical/Surgical Procedures.
Precertification is not required for: • Outpatient services • Medicare primary contracts • Coordination of benefits contracts All inpatient partial and residential mental health and substance abuse facilities are required to notify New Directions for all admissions and discharges; most admissions will require a clinical review. You may
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