Forms

The forms in this online library are updated frequently—check often to ensure you are using the most current versions. Some of these documents are available as PDF files. If you do not have Adobe® Reader®, download it free of charge at Adobe's site.

Types of Forms

Appeal/Disputes

Form Title Network(s)
Expedited Pre-service Clinical Appeal Form Commercial only 
Medicaid Claims Inquiry or Dispute Request Form Medicaid only (BCCHP and MMAI)
Medicaid Service Authorization Dispute Resolution Request Form Medicaid only (BCCHP and MMAI)


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Behavioral Health (Commercial)

Form Title Network(s)
Applied Behavior Analysis (ABA) Clinical Service Request Form Commercial only 
Applied Behavior Analysis (ABA) Initial Assessment Request Form Commercial only 
Coordination of Care Form All Networks
Electroconvulsive Therapy (ECT) Request Form Commercial only 
Intensive Outpatient Program (IOP) Request Form Commercial only 
Psychological/Neuropsychological Testing Request Form Commercial only 
Repetitive or Deep Transcranial Magnetic Stimulation Commercial only 
Therapeutic Behavioral On-Site Services Request Commercial only
Transitional Care Request Form Commercial only


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Behavioral Health (Medicaid Only - BCCHP and MMAI)

Form Title Network(s)

Applied Behavior Analysis - Clinical Service Request Form

Medicaid only

Applied Behavior Analysis - Initial Assessment Request

Medicaid only
Community Based BH Request Form Medicaid only
Electroconvulsive Therapy (ECT) Request Form Medicaid only
Fax Coversheet Medicaid only
Psychological/Neuropsychological Testing Request Form Medicaid only
Transcranial Magnetic Stimulation Request Form Medicaid only


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Behavioral Health (Medicare Advantage PPO)

Form Title Network(s)
Electroconvulsive Therapy (ECT) Request Form  Medicare Advantage PPO 
Psychological/Neuropsychological Testing Request Form  Medicare Advantage PPO 
Transcranial Magnetic Stimulation Request Form  Medicare Advantage PPO 


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Claim Reporting/Results/Resolution

Form Title Network(s)
Check and Voucher Request Form Commercial only
Medicare Reconsideration Form Commercial only
Provider Refund Form Commercial (professional only) 


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Claim Review

Form Title Network(s)
Additional Information Claim Form Commercial only 
Claim Review Form Commercial only 
Corrected Claim Form Commercial only 


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Claim Review (Medicare Advantage PPO)

Form Title Network(s)
Claim Review (Medicare Advantage PPO) Medicare Advantage PPO only 


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Credentialing/Contracting

Form Title Network(s)
Attestation for Provider Credentialing Commercial, MA HMO, MA PPO and MMAI
Hospital Coverage Letter - Updates in progress Commercial, MA HMO, MA PPO and MMAI



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Durable Medical Equipment (DME)

Form Title Network(s)
Durable Medical Equipment (DME) Benefit Limits Verification Request Form Medicaid only (BCCHP and MMAI)


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Electronic Access/Enrollment

Form Title Network(s)
 HMO Online Access Request Form HMO Commercial and MA HMO


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Fee Schedule

Form Title Network(s)
Fee Schedule Request - Blue Choice PPOSM Commercial Only
Fee Schedule Request - PPO Commercial Only


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Medical Policy (Documentation)

Form Title Network(s)
Hyperbaric Oxygen (HBO) Pressurization Form  All Networks
Wheelchair Medical Necessity and Home Evaluation Verification Form  All Networks


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Member Information/Release Forms

Form Title Network(s)
Behavioral Health Release of Information Form - Sample  All Networks
COB Questionnaire  All Networks
Dependent Student Medical Leave Form  All Networks
Standard Authorization Form to Use or Disclose PHI  All Networks


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Network Participation/Provider Updates

Form Title Network(s)
Demographic Change Form  All Networks
Provider Onboarding Form All Networks


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Pharmacy

Form Title Network(s)
Refer to the Pharmacy Program section for more information. All Networks
Uniform Prior Authorization Form Commercial Only
Synagis Prior Authorization Form Medicaid (BCCHP only)


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Pre-service Review

Form Title Network(s)
 Medicaid Prior Authorization Request Form Medicaid only (BCCHP and MMAI)
 Predetermination Request Form Commercial, non-HMO


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Wellness

Form Title Network(s)
Medicare Advantage Annual Wellness Visit Form Medicare Advantage Plans


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