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

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 Behavioral Analysis - BCBA Transfer Form Commercial only
Applied Behavior Analysis - Clinical Service Request Form Commercial only
Applied Behavior Analysis - Initial Assessment Request Form Commercial only
Coordination of Care Form All Networks
Discharge Clinical Form Commercial only
Electroconvulsive Therapy (ECT) Request Form Commercial only
Intensive Outpatient Program (IOP) Request Form Commercial only
Post Service Review Request Form Commercial only
Predetermination Request Form Commercial, non-HMO
Psychological/Neuropsychological Testing Request Form Commercial only
Repetitive or Deep Transcranial Magnetic Stimulation Commercial only
Therapeutic Behavioral On-Site Services Request Commercial only
Transitional Care Request Form Commercial only

Behavioral Health (Medicaid Only - BCCHP and MMAI)

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

Claim Reporting/Results/Resolution

Form Title Network(s)
Check and Voucher Request 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)
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/Release Forms

Form Title Network(s)
Behavioral Health Release of Information Form - Sample All Networks
COB Questionnaire 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
Uniform Prior Authorization Form Medicaid (BCCHP Only
Synagis Prior Authorization Form Medicaid (BCCHP only)
Affordable Care Act (ACA) Copay Waiver Form Commercial Only
Affordable Care Act (ACA) Program Summary Commercial Only
Formulary Coverage Exception Form Commercial Only

Pre-service Review

Form Title Network(s)
AI/AN Limited Cost-Sharing Referral Form American Indian and Alaska Native
Medicaid Prior Authorization Request Form Medicaid only (BCCHP and MMAI)
Recommended Clinical Review (Predetermination) Form Commercial, non-HMO

Wellness

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

Insurance Basics

Buying a Health Plan

Member Resources

Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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