Health Care Provider Forms

General

Form	Description
Claim Review Note: Review each form to determine the appropriate form to use   Additional Information Form Claim Review Form Corrected Claim Form	Additional Information Form  Claim Review Form  Corrected Claim Form
Coordination of Benefits	Online Questionnaire Interactive Questionnaire
Dependent Student Medical Leave Certification Form
Hemophilia Referral Fax	Interactive
Hospital Coverage Letter	Interactive
Medicare Advantage Annual Wellness Visit guide	Interactive
Medicare Advantage Annual Wellness Visit Form	Interactive
Out-of-Network — Enrollee Notification Form for Regulated Business (Use this form if "TDI" is on member's ID card)
Out-of-Network — Enrollee Notification Form for Non-Regulated Business (Use this form if "TDI” is not on member's ID card)
PPO Notification for non pre-cert surgeries per Texas Administrative Code 3.3703
Predetermination Request	Fillable
Prior Authorization
Provider Refund	Fillable
Room Rate Update Notification	Fillable
Urine Drug Testing Form for Out-of-Network Providers	Interactive
Verification Request	Interactive

Electronic Payment Solutions

Form	Description
Availity.com	Save time and enroll online for Electronic Funds Transfer and Electronic Remittance Advice. Learn more.

Medical Policy Forms (Note: May be used as a supplement to medical record documentation)

Form	Description
Bariatric Surgery	Interactive
Botulinum Toxin	Interactive
Cranial Remolding Orthosis (CRO) Device	Interactive
Erythropoiesis-Stimulating Agents (ESAs)	Fillable
Genetic Testing	Instructions  Fillable
Growth Hormone	Interactive
Hyperbaric Oxygen (HBO) Pressurization	Interactive
Immunoglobulin Therapy	Interactive
Oncotype DX	Interactive
Remicade	Interactive
Varicose Vein Management	Interactive
Wheelchair Medical Necessity and Home Evaluation Verification	Interactive

Behavioral Health/Mental Health Forms for ERS Participants

Behavioral Health Forms for TRS Participants

Behavioral Health for Other BCBSTX Plans

(Note: for ERS or TRS participants refer to specific form links above)

Form	Description
Applied Behavior Analysis (ABA) forms: ABA Clinical Service Request Form  ABA Initial Assessment Request   Supervision via Telehealth Request – Attestation
Coordination of Care
Electroconvulsive Therapy (ECT) Request
Intensive Outpatient Program (IOP) Request
Psychological/Neuropsychological Testing Request
Repetitive Transcranial Magnetic Stimulation (rTMS)
Transitional Care Request

Pharmacy

Form	Description
Express Scripts® Pharmacy Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions	Fax forms must be faxed from a physician's office
Accredo Specialty Pharmacy General Use Fax Form	Specialty pharmacy drugs fax form for general use
Accredo Specialty Pharmacy Referral Forms by Therapy	Specialty pharmacy drugs fax form by drug therapy
Quantity Limit Override Request	Request to override the dispensing/quantity limit
Topical Verapamil Override Request