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
Behavioral Health (Commercial)
Behavioral Health (Medicaid Only - BCCHP and MMAI)
Behavioral Health (Medicare Advantage PPO)
Claim Reporting/Results/Resolution
Claim Review
Claim Review (Medicare Advantage PPO)
Credentialing/Contracting
Durable Medical Equipment (DME)
Electronic Access/Enrollment
Fee Schedule
Medical Policy (Documentation)
Member Information/Release Forms
Network Participation/Provider Updates
Pharmacy
Pre-service Review
Wellness

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)

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 Transcranial Magnetic Stimulation (rTMS)	Commercial only
Transitional Care Request Form	Commercial only

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 (rTMS) Request Form	Medicaid only

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 (rTMS) Request Form	Medicare Advantage PPO

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)

Claim Review

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

Claim Review (Medicare Advantage PPO)

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

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

Durable Medical Equipment (DME)

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

Electronic Access/Enrollment

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

Fee Schedule

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

Medical Policy (Documentation)

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

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

Network Participation/Provider Updates

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

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)

Pre-service Review

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

Wellness

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