Looking for the right form or document to help care for your patients? Find what you need to get your work done quickly.
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Assessment forms
Michigan providers should attach the completed form to the request in the e-referral system. Non-Michigan providers should fax the completed form using the fax numbers on the form.
Michigan providers should attach the completed form to the request in the e-referral system. Non-Michigan providers should fax the completed form using the fax numbers on the form.
Michigan and non-Michigan providers should fax the completed form using the fax numbers on the form.
For Medicare Plus Blue and BCN Advantage members: Michigan providers should attach the completed form to the request in the e-referral system. Non-Michigan providers should fax the completed form using the fax numbers on the form.
Blue Cross Complete
This document identifies the basic terms of drug coverage for Blue Cross Complete members.
Use this guide to understand which specialty drugs are covered by Blue Cross Complete.
This lists the medicines Medicaid pays for instead of Blue Cross Complete of Michigan.
When prescribing medications for Blue Cross Complete members, please refer to this drug list.
Refer to this list to see which drugs require prior authorization and what the criteria are for each drug.
Fill out this form to request prescription drug coverage for your patient.
Care management and support services
Learn about our care management and utilization management offerings and how they're covered.
This form is used with our wellness plans, like Healthy Blue Achieve, to request a medical waiver for a patient or update a patient's progress.
Answers frequently asked questions about the Blue Cross Coordinated Care program, which is available to members with commercial plans and with Medicare Advantage plans.
Answers frequently asked questions about the Landmark high-intensity in-home care program for members with Medicare Advantage plans.
Answers frequently asked questions about the Cancer Support program, which is available to many members with commercial plans.
Learn about our Family Building and Women’s Health Support Solution, which is available to many members with commercial plans.
Learn about our nonclinical, transitional care program to help reduce avoidable inpatient readmissions for Medicare Advantage members
Answers frequently asked questions about the DMEPOS management program for commercial and Medicare Advantage members in Michigan.
Provides access to a list of procedure codes that require prior authorization for the Northwood DMEPOS management program for commercial and Medicare Advantage members in Michigan.
Learn about all the steps you can take to maintain a safe, confidential and secure work area regardless of work location.
COVID-19
Learn how you can sign up and use this program to ensure your patients have COVID-19 vaccine coverage.
Read about our testing policies and how to code and bill for tests.
Read about our testing policies and how to code and bill for tests involving our Medicare Advantage members.
Medical chart review reimbursem*nt
If you've supplied our vendor, Ciox Health, with medical charts for Medicare Plus Blue PPO, you can request reimbursem*nt with this form.
If you've supplied medical records to a Blue Cross HEDIS clinical consultant performing HEDIS retrievals, you may request reimbursem*nt with this form or through your HEDIS clinical consultant. We only reimburse for Blue Cross Medicare Plus Blue, Blue Cross Commercial PPO and Marketplace PPO members.
Medicare Advantage
View all our drugs lists along with guidelines for step therapy and prior authorization requests.
Learn about our enhanced benefit policies for Medicare Plus Blue℠ PPO plans for individuals and groups.
Learn about our enhanced benefit policies for BCN Advantage plans for individuals.
Waiver of Liability
Medicare sometimes denies payment for certain health care services. If you're a non-contracted provider you can try to appeal a Medicare denial. As part of the process, you'll have to fill out the above form. You can find this and the other requirements for an appeal at the Centers for Medicare & Medicaid Services.
To learn about reimbursem*nt for professional services under BCN Advantage, refer to this fee schedule.
The Medicare Advantage PPO Provider Agreement includes a base agreement that applies to all providers.
This document applies to practitioners participating in Medicare Plus Blue PPO.
This document applies to hospitals participating in Medicare Plus Blue PPO.
This document applies to non-hospital facilities participating in Medicare Plus Blue PPO.
This document applies to rural facilities participating in Medicare Plus Blue PPO.
This document applies to federally qualified health clinics participating in Medicare Plus Blue PPO.
ESRD facilities should refer to this fee schedule when caring for a Medicare Plus Blue PPO patient. Member copayments and deductibles apply.
To learn about reimbursem*nt for enhanced benefits under Medicare Plus Blue PPO, refer to this fee schedule.
Blue Cross Blue Shield of Michigan has partnered withAdvantasure in their Remote Clinical DocumentationImprovement Program. This program helps providersmake complete and accurate diagnoses of our Medicare Plus Blue PPO members.
Use this alert as a guide during the face-to-face or telehealth (audio and visual component) patient visit.
This document contains information about prior authorizations, requests for durable medical equipment, preservice and post-service appeals and claims submissions.
Use this alert as a guide during the face-to-face or telehealth (audio and visual component) patient visit.
This tip sheet can help you complete a CDI alert.
Use this guide as a reference when completing the Star Measure Gap Closure section of the CDI Alert.
Pharmacy services
View all our drugs lists along with guidelines for step therapy and prior authorization requests.
Specialty drugs are prescription medications that require special handling, administration or monitoring. They may need special handling and monitoring.
We limit certain specialty drugs to a 15-day supply limit to reduce copays and drug waste.
Here's all the participating pharmacies in Michigan.
Optum Rx® Pharmacist Resource Center
If you need help with an Optum Rx issue, visit their health care professionals website for answers.
Recredentialing
If you need to recredential as a clinical independent laboratory, durable medical equipment supplier, freestanding radiology center, Medicare-approved ambulatory surgical facility, Medicare-approved physiological laboratory or urgent care center, use this form.
All other hospitals and facility types can use this form to recredential.
Referral forms
Use e-referrals to complete referrals for any BCN patients.
Dentists can use this form when they see a medical issue that needs a referral to a physician.
Physicians can use this to refer a patient for a comprehensive oral assessment and dental treatment.
Use this form when you need to refer to a non-UAW Trust PPO participating practitioner, facility, ancillary provider or laboratory.
Only Michigan PPO providers for U.P. Blue Cross members can use this form. It can't be used by out-of-state providers.
This is for referring patients with an individual plan who are out of state.
Supply forms
Fill this out to order general administrative materials you need when doing business with Blue Cross
This form is used with our wellness plans, like Healthy Blue Achieve, to request a medical waiver for a patient or update a patient's progress.
