Mandatory Prior Authorization
As a result of the Michigan prior authorization legislation (referred to as Public Act 60) signed into law on April 7, 2022, health care providers must electronically submit prior authorization (PA) requests beginning June 1, 2023.
MESSA members do not need to take any action. The provider is responsible for submitting mandatory prior authorization.
In order for providers to submit requests through the MESSA Provider Portal, users must first register. MESSA recommends setting up an account in the portal as soon as possible. Users will receive an email with login credentials once the portal is ready to use. The MESSA Provider Portal user guide introduces the user to the basic navigation and the use of features within the portal. If the MESSA Connect System is disabled, please call 800-336-0013 to request a paper registration form.
Please note: Requests for admission to a facility must be submitted as an inpatient authorization through the MESSA portal. All other requests must be submitted as an outpatient authorization through the MESSA portal.
Requests for services that require mandatory prior authorization require a response within 9 days of submission for standard requests and within 72 hours for urgent requests.
Urgent is defined as “an insured or enrollee is suffering from a health condition that may seriously jeopardize the insured’s life, health, or ability to regain maximum function or could subject the insured or enrollee to severe adverse health consequences that cannot be adequately managed without the care or treatment that is the subject of the prior authorization.”
Providers must certify that urgent requests meet the Public Act 60 definition.
Click here for a list of services that require mandatory prior authorization and where to request.
Click here for drugs covered under the BCBSM medical benefit.
The following criteria are used to determine medical necessity (links from BCBSM):
Click here for the behavioral health admissions criteria.
Benefit Review Requests
As a courtesy, MESSA will review other items and services, not listed above, for coverage determinations. These are referred to as benefit review requests and do not apply to the Public Act 60 requirements above. Please submit requests through the portal.