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Types of Forms
- Appeals and Disputes
- Behavioral Health (Commercial)
- Behavioral Health (Medicaid only)
- Behavioral Health (Medicare Advantage PPO)
- Claim Reporting, Results and Resolution
- Claim Review
- Claim Review (Medicare Advantage PPO)
- Credentialing and Contracting
- Durable Medical Equipment
- Electronic Access and Enrollment
- Fee Schedule
- Long-Term Services and Support Gaps
- Medicaid Training Attestation
- Medical Policy (Documentation)
- Member Information and Release Forms
- Network Participation and Provider Updates
- Pharmacy
- Preservice Review
- Wellness
Appeal and Disputes
| Form Title | Networks |
|---|---|
| Expedited Preservice Clinical Appeal Form | Commercial only |
| Medicaid Claims Inquiry or Dispute Request Form | Medicaid only |
| MMAI Claims Inquiry or Dispute Request Form | (This form is applicable for dates of service through Dec. 31, 2025.) |
| Medicaid Service Authorization Dispute Resolution Request Form | Medicaid only |
| Provider BlueCard Claim Appeal Form | Commercial, non-HMO |
Behavioral Health (Commercial)
| Form Title | Networks |
|---|---|
| Coordination of Care Form | All networks |
| Discharge Clinical Form | Commercial only |
| Intensive Outpatient Program (IOP) Request Form | Commercial only |
| Post Service Review Request Form | Commercial only |
| Recommended Clinical Review Form | Commercial, non-HMO |
| Transcranial Magnetic Stimulation Request | Commercial only |
| Therapeutic Behavioral On-Site Services Request | Commercial only |
| Request for Continued Access to Providers | Commercial only |
Behavioral Health (Medicaid only)
| Form Title | Networks |
|---|---|
| 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 |
| Out-of-Network – Behavioral Health Outpatient Request Form | Medicaid only |
| Psychological/Neuropsychological Testing Request Form | Medicaid only |
Behavioral Health (Medicare Advantage PPO)
| Form Title | Networks |
|---|---|
| Electroconvulsive Therapy (ECT) Request Form | Medicare Advantage PPO |
| Psychological/Neuropsychological Testing Request Form | Medicare Advantage PPO |
| Transcranial Magnetic Stimulation Request Form | Medicare Advantage PPO |
Claim Reporting, Results and Resolution
| Form Title | Networks |
|---|---|
| Check and Voucher Request Form | Commercial only |
| Provider Refund Form | Commercial (professional only) |
Claim Review
| Form Title | Networks |
|---|---|
| Additional Information Claim Form | Commercial only |
| Claim Review Form | Commercial only |
| Corrected Claim Form | Commercial only |
Claim Review (Medicare Advantage PPO)
| Form Title | Networks |
|---|---|
| Claim Review (Medicare Advantage PPO) | Medicare Advantage PPO only |
Credentialing and Contracting
| Form Title | Networks |
|---|---|
| Independent Lab Supplemental Form | Commercial (non-HMO), Medicare Advantage plans (HMO and PPO), Medicaid |
Durable Medical Equipment
| Form Title | Networks |
|---|---|
| Durable Medical Equipment (DME) Benefit Limits Verification Request Form | Medicaid only |
Electronic Access and Enrollment
| Form Title | Networks |
|---|---|
| HMO Online Access Request Form | HMO (commercial and Medicare Advantage) |
Fee Schedule
| Form Title | Networks |
|---|---|
| Fee Schedule Request - Blue Choice PPOSM | Commercial only |
| Fee Schedule Request - PPO | Commercial only |
Long-Term Services and Support Gaps
| Form Title | Networks |
|---|---|
| Explanation for Gaps in LTSS | Medicaid only |
Medicaid Training Attestation
| Form Title | Networks |
|---|---|
| Medicaid Training Attestation | Medicaid only |
Medical Policy (Documentation)
| Form Title | Networks |
|---|---|
| Anti-VEGF Intravitreal Injection Therapy Verification Form | Commercial only |
| Hyperbaric Oxygen (HBO) Pressurization Form | All networks |
| Wheelchair Medical Necessity and Home Evaluation Verification Form | All networks |
Member Information and Release Forms
| Form Title | Networks |
|---|---|
| Behavioral Health Release of Information Form - Sample | All networks |
| COB Questionnaire | All networks |
Network Participation and Provider Updates
| Form Title | Networks |
|---|---|
Demographic Change Form  | All networks |
| Provider Onboarding Form | All networks |
| Universal Illinois Association of Medicaid Health Plans Roster | All networks |
Pharmacy
| Form Title | Networks |
|---|---|
| Refer to the Pharmacy Program section for more information. | All networks |
| Free Market Health (health care technology company with non-dispensing specialty pharmacy): ePrescribe NCPDP: 6013914; NPI: 1366292880, email contact@fmhpharmacy.com, call 412-755-3241 or fax 833-998-4435 | Submit new or transfer existing prescriptions for specialty and complex care drugs. Call 877-787-0520 or email prescribers@freemarkethealth.com with any questions. Not available for all BCBSIL commercial plans |
| Uniform Prior Authorization Form | Commercial only |
| Uniform Prior Authorization Form | Medicaid only |
| Synagis Prior Authorization Form | Medicaid only |
| Affordable Care Act (ACA) Copay Waiver Form | Commercial only |
| Affordable Care Act (ACA) Program Summary | Commercial only |
| Formulary Coverage Exception Form | Commercial only |
| Tier Exception Form | Commercial only |
| Tier Exception Program Summary | Commercial only |
Preservice Review
| Form Title | Networks |
|---|---|
| AI/AN Limited Cost-Sharing Referral Form | American Indian and Alaska Native |
| Medicaid Prior Authorization Request Form | Medicaid only |
| Recommended Clinical Review Request Form | Commercial, non-HMO |
| Medical Benefit Therapeutic Alternatives Coverage Exception Request Form | Commercial only |
Wellness
| Form Title | Networks |
|---|---|
| Medicare Advantage Annual Wellness Visit Form | Medicare Advantage plans |