Provider Forms & Policies

For Mississippi Network Providers

Forms

Contraceptive Coverage Exception Form Contraceptive Coverage Exception requests must be submitted through the Be RxSmart section in your myBlue Provider account.

Electronic Solutions View our Electronic Solutions page to learn about setting up electronic submission, resolving common errors and claim reject reasons.

Provider Administration Update Forms Inform us about changes in Provider information by submitting the applicable form below.

• Professional

• Institutional Ancillary

Policies

Medical Policy Medical Policy is used by BCBSMS as one set of guidelines to assist BCBSMS in making benefit coverage decisions.

Coding Policy BCBSMS follows CPT, HCPCS and ICD-10-CM national coding guidelines.

Healthy You! Wellness Procedures Coding Guidelines Click to view our library of Healthy You! procedure and diagnosis codes.

Healthy You! Wellness Benefit Learn more about the Healthy You! wellness benefit.

Transplant Travel and Lodging Reimbursement Policy Click the link above to read the BCBSMS Transplant Travel and Lodging Reimbursement Policy.

For Out-of-State and Non-Network Providers

No Surprise Billing Information for Non-Network Providers Reference for information on how the No Surprises Act protects consumers from surprise billing and impacts the process of payments.

Online Authorization Forms

• Submit an Outpatient and Professional Services Authorization Request

• Submit a Mental Health and Substance Abuse Authorization Request

• Submit a Prescription Drug Prior Authorization Request

• Submit a Prescription Drug Prior Authorization Appeal

• Submit a Home Infusion Therapy Request Form

• Submit a Home Health & Hospice Authorization Request Form

• Submit a Transplant Prior Authorization Request

Inpatient Care Coordination Forms

• Submit Hospital Inpatient Care Coordination Information

• Submit Continued Stay or Discharge Care Coordination Information

Care-Related

• Durable Medical Equipment Certification Form

• Medical Transport Prior Approval Request

Administrative

• Provider Correspondence Form

• Modifier Usage Guidelines

• Coordination of Benefits Questionnaire

• Provider Remote System Access Agreement

• BCBSMS Electronic Submission of Claims Agreement

• Pharmacy System Access Agreement