Blue Cross Blue Shield Texas Managed Care Out of Network Request Form
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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) |
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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 |
| 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 - BlueChoice 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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Source: https://www.bcbsil.com/provider/education/education-reference/forms
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