Blue Cross Blue Shield of Michigan Outpatient Physical Therapy prior authorization requirements (2026)
What Blue Cross Blue Shield of Michigan generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Commercial plans. Based on the cited policy, Blue Cross Blue Shield of Michigan does not generally require prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035). Confirm with Blue Cross Blue Shield of Michigan, as this can vary by plan.
Medical-necessity criteria Blue Cross Blue Shield of Michigan generally applies
No prior-authorization program applies to outpatient PT for Blue Cross (BCBSM) commercial members: the BCBSM/BCN utilization-management document for PT/OT/ST (revised June 2026) applies the eviCore therapy authorization program only to BCN commercial and BCN Advantage, not Blue Cross commercial. Member benefit limits (visit caps by group) still apply - verify eligibility and benefits before treating. TurningPoint manages musculoskeletal SURGERY and pain-management procedures, not therapy visits; Northwood is DME only. An optional Hinge Health virtual MSK program exists for some groups with no referral or prior authorization.
Commonly required documentation
- No PA submission applies. Keep the order/referral per the member's plan, the evaluation and plan of care, and objective progress documentation for any post-payment review.
How to submit
- Method: Verify eligibility/benefits via Availity
- Portal: Availity
Sources & verification
Sources: BCBSM UM doc (rev. June 2026); https://www.bcbsm.com/important-information/prior-authorization/. Applies to Blue Cross COMMERCIAL only - do NOT infer anything for Medicare Plus Blue (MA), which was not verified. [NEEDS CLINICAL SPOT-CHECK] View the source policy. Last verified 2026-07-09.
Frequently asked questions
Does Blue Cross Blue Shield of Michigan require prior authorization for Outpatient Physical Therapy?
Based on the cited policy, Blue Cross Blue Shield of Michigan does not generally require prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035). Confirm with Blue Cross Blue Shield of Michigan, as this can vary by plan.
What does Blue Cross Blue Shield of Michigan require to approve Outpatient Physical Therapy?
No prior-authorization program applies to outpatient PT for Blue Cross (BCBSM) commercial members: the BCBSM/BCN utilization-management document for PT/OT/ST (revised June 2026) applies the eviCore therapy authorization program only to BCN commercial and BCN Advantage, not Blue Cross commercial. Member benefit limits (visit caps by group) still apply - verify eligibility and benefits before treati… Always confirm against the current Blue Cross Blue Shield of Michigan policy.
How long does a Blue Cross Blue Shield of Michigan prior authorization take?
Turnaround varies by plan and submission method. Check the Blue Cross Blue Shield of Michigan portal for current timeframes.
Submitting Outpatient Physical Therapy to Blue Cross Blue Shield of Michigan?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.