Provider Forms

A big part of helping patients succeed in taking ownership of their health is their relationship with you as their healthcare provider. Our Healthy You! benefit helps our members work with you to find their health status and learn what lifestyle changes they need to make and what other treatment they may need.

To help you file claims regarding Healthy You!, we've published a library of Healthy You! procedure and diagnosis codes. Click here to download the Healthy You! codes. You also can learn more about the Healthy You! benefit.

Because electronic filing of claims is so important to provide efficient service to you and your patients, we have included forms to help you file claims electronically. Please review these forms to learn about setting up electronic submission, resolving common errors and claim reject reasons.

To inform us about changes in provider information, click here to download the Provider Administration Communication Form as an editable .pdf document.

The forms below are online submission. Simply click on the form name to open them.

Nervous, Mental and Substance Abuse Prior Approval Form

The forms below are all PDF documents. Simply click on the form name to open them.

Provider Correspondence Form

General Prior Authorization (PA) Form

Modifier Usage Guidelines

Coordination of Benefits Questionnaire

Durable Medical Equipment Certification Form

Precertification Request, Inpatient Medical-Surgical

Continued Stay Request, Medical-Surgical

Home Health Evaluation Request

Home Infusion Therapy Pre-certification Request

Medical Transport Prior Approval Request

Provider Remote System Access Agreement and associated Disclosure Agreement

BCBSMS Electronic Submission of Claims Agreement

BlueCard Manual