Providers

Prior Authorization Resources

Blue Cross Complete of Michigan's self-service tools are valuable resources that can assist you in providing the highest quality of care to our members.

NaviNet

Enter prior authorization requests, access member eligibility and status claims using the provider portal NaviNet.

By logging on to the Blue Cross Complete payer-provider portal Navinet, you have the opportunity to:

  • Receive news alerts in real time
  • View Blue Cross Complete member information
  • Submit authorization requests
  • View gaps in care reports 
  • Check the status of claims

Use the NaviNet Medical Authorizations Participant Guide (PDF) to learn more about using the NaviNet Medical Authorization system. Refer to the NaviNet Medical Authorizations Frequently Asked Questions (PDF) to review commonly asked questions.

The Care Gap Response Form Guide (PDF) contains detailed information for providers about how to use NaviNet to enter Care Gap resolution data online. This guide explains how to retrieve and report on specific Care Gap changes.

The Condition Optimization Program Provider User Guide (PDF) contains details about how providers access Condition Optimization Program workflow activities within NaviNet.

Visit NaviNet Basics if you have not yet enrolled or would like more information.

Prior Authorization Lookup Tool

Find out if a service needs prior authorization. Type a Current Procedural Terminology, or CPT, code or a Healthcare Common Procedure Coding System, or HCPCS, code in the space below to get started.

Important notice

This tool provides general information for outpatient services performed by a participating provider. Prior authorization requirements also apply to secondary coverage. 

The following services always require prior authorization: 

  • Inpatient services (elective and urgent)
  • Codes not on the Michigan Medicaid Fee Schedule 

If you have questions about this tool, a service or to request a prior authorization, contact Utilization Management at 1-888-312-5713.

Directions

  1. Enter a CPT or HCPCS code in the space below.
  2. Click Submit.
  3. The tool will tell you if that service needs prior authorization.

DISCLAIMER
The following attempts to provide the most current information for the Pre-Authorization Look-Up Tool. Please note that this information may be subject to change, and a Pre-Authorization is NOT a guarantee of payment. Payment is dependent on a number of factors, including but not limited to member eligibility on the date of service, coverage limitations and exclusions, provider contracts, and correct coding and billing for the services at issue. Blue Cross Complete reserves the right to adjust any payment made following a review of the medical records and determination of medical necessity for the services rendered. For additional details, or if you are uncertain that pre-authorization is needed, please see the Provider Manual on the Blue Cross Complete website.

Prior authorization

Refer to the Prior Authorization Requirement Updates (PDF) to view the most recent updates to the Prior Authorization Lookup tool.

Use the Utilization management authorization request form (PDF) to submit for prior, concurrent or retrospective review authorization requests.

Some medicines and benefits require prior authorization by Blue Cross Complete. Submit a prior authorization request using one of the following forms:

You must submit a request for a prior authorization for your patient. You must also submit an override of a drug restriction. Request from pharmacies aren't accepted.

Blue Cross Complete offers our providers access to Medical Authorizations for electronic authorization inquiries and submission. The Medical Authorizations portal is accessed through NaviNet located on the Workflows menu.

In addition to submitting and inquiring on existing authorizations, you will also be able to:

  • Verify if No Authorization is Required
  • Receive Auto Approvals, in some circumstances
  • Submit Amended Authorization
  • Attach supplemental documentation
  • Sign up for in-app status change notifications directly from the health plan
  • Access a multi-payer Authorization log
  • Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities (fax is no longer required)
  • Review inpatient admission notifications and provide supporting clinical documentation

A prior authorization for healthcare common procedure coding system medications is required before they are covered by Blue Cross Complete. Click the HCPCS PA List (PDF) for a list of codes that require prior authorization.

Effective May 1, 2022, Blue Cross Complete will require prior authorization from Evolent, formerly National Imaging Associates, Inc., for most non-emergency outpatient diagnostic imaging services. Providers are encouraged to use resources below, visit RadMD.com or call Evolent at 1-800-424-5351.