Fillable Blue Cross Blue Shield of Michigan Request for (Blue Cross Blue Shield of Michigan)

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Blue Cross Blue Shield of Michigan Request for (Blue Cross Blue Shield of Michigan)

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Blue Cross Blue Shield of Michigan Request for Preauthorization Form
Most preauthorization requests can be resolved by contacting Provider Relations and Servicing, or PRS, and requesting member benefits.
However, if you would like to submit a request for preauthorization after contacting PRS, you may submit a written request by completing this
form. Include any documents to support your request, send a copy of your documents and keep all originals. Please only submit one
preauthorization per form.
☐ Urgent Request
☐ Non-urgent Request
Only life-threatening situations will be considered for urgent requests.
Provider Information
Provider’s Name
Requesting Provider NPI/PIN
Provider Telephone Number
Address
City
State
Zip Code
Contact Name
Contact Telephone Number
Contact Fax Number
Enrollee/Patient Information
Enrollee’s Name
Date of Birth
Enrollee ID
Group Number
Patient’s Name
Patient’s Date of Birth
Daytime Telephone Number
Address
City
State
Zip Code
Preauthorization Section
Procedure/HCPCS Codes
ICD-10 Diagnosis Codes
Preauthorization Description
Fax: 1-866-311-9603
Provider Inquiry, Preapproval – Mail Code 0450
Blue Cross Blue Shield of Michigan
P.O. Box 2227
Detroit, MI 48231-2227
June 2020
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Blue Cross Blue Shield of Michigan Request for (Blue Cross Blue Shield of Michigan)

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Completed 24 May 2022

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