Provider Forms and Documents

General Forms

• Additional Information Form  Additional Information requested may be submitted with the letter received or this form.
  DO NOT USE THIS FORM UNLESS YOU HAVE RECEIVED A REQUEST FOR INFORMATION.
  Original Claims should not be submitted with this form.
• Advance Member Notification Form  Advance Member Notification refers to the process in which a provider informs a member that a service, supply, device, or drug is not likely to be considered for compensation by BCBSMT prior to the service being performed.
• Advance Member Notification Form - Spanish version 
• Three Character Prefix 
• Authorization for Disclosure of Individual's Health Information or the Standard Authorization Form (SAF)  Use this form to authorize BCBSMT to disclose information to another person or entity.
• Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) enroll online via Availity ^® . For assistance, refer to the Availity EFT & ERA Enrollment User Guide in the Claims and Eligibility/Claim Payment and Remittance section of our website.
• Change of Status Form (Provider) Use this form to notify Health Care Services of changes to your address, telephone, tax ID, and any other information used to process BCBSMT claims.
• Check and Voucher Request Form . Use this form if you are faxing a check or voucher request directly to Blue Cross Blue Shield of Montana (BCBSMT)
• Claim Form For The Blue Cross and Blue Shield Parties' Settlement Fund and Election of Contribution to Charitable Foundation or Organization  Instructions 
• Claim Review Form  This form is only to be used for review of a previously adjudicated claim. Original Claims should not be attached to a review form. Do not use this form to submit a Corrected Claim or to respond to an Additional Information request from BCBSMT.
• CMS-1500 Claim Form (Version 02/12)  Instructions for completing CMS-1500 Form (Version 02/12) . Professional Providers use this form to request compensation for medical services. Print and use this form in color so our optical character recognition scanner can read your claim.
• Continuing Medical Education (CME) Attestation  MD's, DO's, DPM's and CPP's use this form when completing the recredentialing process. Please email your completed document to mt_hcsspec@bcbsmt.com, or you may fax it to 406-437-7879.
• Corrected Claim Form  This form is only to be used to make corrections to a previously adjudicated claim when you are unable to submit the corrections electronically. Do not use this form to respond to an Additional Information request from BCBSMT.
• Expedited Pre-service Clinical Appeal Form 
• Hospital Coverage Letter (HCL)  Use this form if you are a MD, or DO, and you do not have current active hospital admitting privileges. Please email your completed document to mt_hcsspec@bcbsmt.com, or you may fax it to 406-437-7879.
• Hospital Room Rate Update Form  - Remember to submit room rate updates 30 days prior to implementing the material change.
• HMK Screening Application Form  Use this form to fulfill CMS eligibility requirements for providers who do not currently participate in Medicare or Medicaid. Must have current HMK contract signed with BCBS Montana.
• Medicare Advantage Wellness Visit Form 
• Provider Complaint Form 
• UB-04 Claim Form . Hospitals and facilities use this form to request compensation for medical services. Print and use this form in color so our optical character recognition scanner can read your claim. Use the UB-04 User Guide  document to learn how to complete the UB-04 Claim Form.

Behavioral Health

Additional program information coming soon.

• Behavioral Health Coordination of Care Form 
• Electroconvulsive Therapy Request Form 
• Intensive outpatient Program (IOP) Request Form 
• Psychological or Neuropsychological Testing Form 
• Repetitive Transcranial Magnetic Stimulation Request Form 
• Transitional Care Request Form 
• Depression Screening Questionnaire 

Applied Behavior Analysis (ABA) Initial Treatment Request Forms:

• ABA Initial Assessment Request Form 
• ABA Clinical Service Request Form 
• ABA Telehealth Request Form 

Pharmacy

Physicians can access, complete and submit Prior Authorization and Step Therapy request forms electronically from the CoverMyMeds^® website:

• Submit an electronic prior authorization request 
• For more information on CoverMyMeds^®, click here.

Pharmacy Drug:

• NDC Reimbursement Schedule Request Form 
• Express Scripts^® Pharmacy Mail Order: ePrescribe to EXPRESS SCRIPTS HOME DELIVERY, call 888-327-9791 for faxing instructions. You can also call the pharmacy at 833-715-0942 (for commercial group and retail plan members), 833-599-0729 (for Medicare Part D members) or 833-715-0944 (for Medicare Advantage members).
• Prime Reimbursement Claim Form 
• Ridgeway Mail Order Form 

Pharmacy Predetermination Physician Fax Forms:

• Pharmacy Policy and PA Forms

Accredo Pharmacy Referral:

• General Use Fax Form 
• Referral Forms by Therapy
• Specialty Pharmacy Program Drug List 

Predeterminations (formerly called Prior Authorization) and Pre-Authorization/Precertification

• Certification for Admission Provider Interactive Form . To be used to capture all required key data for pre-authorization.
• Genetic Testing Provider Interactive Form . To be used when requesting genetic testing.
• Healthy Montana Kids (HMK) - General Form . This form is specifically for providers to request predetermination services for HMK members.
• Medicare Advantage Preauthorization List  . Blue Cross Blue Shield of Montana (BCBSMT) Medicare Advantage (PPO) plan and Medicare Advantage HMO plan list of procedures requiring preauthorization.
• Patient Assessment Validation Evaluation Form . To be used when requesting lower extremity prosthetic limbs. Use this form to complete a Patient Assessment Validation Evaluation Test.
• Predetermination DME Provider Interactive Form . If the purchase price is over $1000, complete this form. If the purchase price is $500 or greater, call Customer Service at 800-447-7828 to determine if predetermination is necessary. If predetermination is necessary, complete this form. Specific coverage criteria for some items are explained in medical policy published at www.bcbsmt.com or in the member's contract.
• Predetermination Commercial General Interactive Form . Predetermination is a process BCBSMT uses to make coverage decisions in accordance with medical policy and group or member contracts for a service, supply, drug, or device used to diagnose or treat an illness or condition.
• Predetermination Medicare Advantage Provider Interactive Form . This form is specific to BCBSMT Medicare Advantage Medical benefits. Providers should complete this form and fax it to 855-874-4711.
• Wheelchair Medical Necessity-Home Evaluation Provider Interactive Form . To be used when requesting wheelchairs and accessories.

Blue Value^sm Total Health Management

THM is an innovative wellness program offered exclusively to BCBSMT group clients and is only available to members of group plans that offer the program as part of their benefit plan. THM uses sound clinical guidelines, specific goals, and effective incentives to help achieve results. Members work with a primary care provider to achieve specific goals.

• THM Assessment Form

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.