Out-of-Area (BCBS Participating Provider) and Out-of-Network provider resources.
Below are several forms commonly used by providers.
To help simplify your administrative tasks, you may download and print these forms.
Preauthorization request forms
- Home health fax form - Home health skilled nursing and/or therapy visit treatment (at home).
- Hospice fax form
- Inpatient elective fax form - Non-urgent/emergent inpatient admissions.
- Peer to peer request form
- Transplant fax form
- Power wheelchairs, power operated vehicles (POV) and related options and accessories preauthorization form
- Therapy fax form - Check Single source list for applicable services. Changes in codes requiring authorization have been made.
- Prior authorization modification and date extension request form This can be used for all authorizations to request future start date, updating diagnosis codes, changing the servicing, or rendering provider. Note: A new authorization form is required to add an additional visit or unit.
- Letter of medical necessity fax form - This form is to be used for all services that don’t have an otherwise explicitly listed form above (such as DME, medical injectable prescriptions, outpatient surgery, genetic testing, other).
- Continuity care form
Preauthorization specialty injectable forms (non-Medicare plans)
- Botulinum toxin preauthorization request form
- Denosumab oncology (Xgeva®) and osteoporosis (Prolia®) preauthorization request form
- Filgrastim preauthorization request form
- Infliximabs preauthorization request form
- Medical injectable drugs (non-drug specific) preauthorization request form
- Ocrevus™ preauthorization request form
- Pegfilgrastim preauthorization request form
- Tysabri® preauthorization request form
- Xolair® preauthorization request form
For services authorized via our musculoskeletal services provider
If the CPT code is listed on the single source preauthorization list and indicates authorization via our musculoskeletal services provider, the following will apply.
Musculoskeletal services post service review process
Please follow the process below for post service surgical reviews:
Step 1
- Provider has received an authorization for requested CPT code(s).
- Following the procedure, the CPT code has changed due to performed surgical procedure:
- CPT code was added to the approved code or instead of the approved code(s).
- Operative note is required for verification of the additional procedure code(s).
Step 2
Complete the post-service claim review form.
- Fill in each section, especially the box indicating the update reason.
- Example: Approval was for CPT 29880 and during surgery, CPT code 29881 was performed.
Step 3
Fax the following information to our musculoskeletal services provider at 717.412.1001.
- Cover sheet with provider information, including contact name and phone number.
- Completed post-service claim review form.
- Operative note: Please make sure the member’s name is listed.
Step 4
Our musculoskeletal services provider will review the faxed information and make a determination within 7-10 business days.
- Our musculoskeletal services provider will notify the provider of the post service determination.
- Our musculoskeletal services provider will notify us of the determination.
- We will verify our records and perform any adjustments, if applicable.
Exclusions
If our musculoskeletal services provider denied the entire surgical request and the procedure was performed, it does not constitute a post service review.
- Provider can appeal the denied determination.