Forms | Blue Cross And Blue Shield Of Illinois

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Types of Forms

  • Appeals and Disputes
  • Behavioral Health (Commercial)
  • Behavioral Health (Medicaid only)
  • Behavioral Health (Medicare Advantage PPO)
  • Claim Reporting, Results and Resolution
  • Claim Review
  • Claim Review (Medicare Advantage PPO)
  • Credentialing and Contracting
  • Durable Medical Equipment
  • Electronic Access and Enrollment
  • Fee Schedule
  • Long-Term Services and Support Gaps
  • Medicaid Training Attestation
  • Medical Policy (Documentation)
  • Member Information and Release Forms
  • Network Participation and Provider Updates
  • Pharmacy
  • Preservice Review
  • Wellness

Appeal and Disputes

Form Title Networks
Expedited Preservice Clinical Appeal Form Commercial only 
Medicaid Claims Inquiry or Dispute Request Form Medicaid only
MMAI Claims Inquiry or Dispute Request Form MMAI only
Medicaid Service Authorization Dispute Resolution Request Form Medicaid only
Provider BlueCard Claim Appeal Form Commercial, non-HMO

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Behavioral Health (Commercial)

Form Title Networks
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 
Intensive Outpatient Program (IOP) Request Form Commercial only 
Post Service Review Request Form Commercial only
Recommended Clinical Review Form Commercial, non-HMO
Transcranial Magnetic Stimulation Request Commercial only 
Therapeutic Behavioral On-Site Services Request Commercial only 
Request for Continued Access to Providers Commercial only 

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Behavioral Health (Medicaid only)

Form Title Networks

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 Networks
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 and Resolution

Form Title Networks
Check and Voucher Request Form Commercial only
Provider Refund Form Commercial (professional only) 

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Claim Review

Form Title Networks
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 Networks
Claim Review (Medicare Advantage PPO) Medicare Advantage PPO only 

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Credentialing and Contracting

Form Title Networks
Independent Lab Supplemental Form Commercial (non-HMO), Medicare Advantage plans (HMO and PPO), Medicaid
Ancillary Credentialing Application Form  
Ancillary Provider Record ID Request Form  

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Durable Medical Equipment

Form Title Networks
Durable Medical Equipment (DME) Benefit Limits Verification Request Form Medicaid only

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Electronic Access and Enrollment

Form Title Networks
HMO Online Access Request Form HMO (commercial and Medicare Advantage)

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Fee Schedule

Form Title Networks
Fee Schedule Request - Blue Choice PPOSM Commercial only
Fee Schedule Request - PPO Commercial only

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Long-Term Services and Support Gaps

Form Title Networks
Explanation for Gaps in LTSS Medicaid only

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Medicaid Training Attestation

Form Title Networks
Medicaid Training Attestation Medicaid only

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Medical Policy (Documentation)

Form Title Networks
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

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Member Information and Release Forms

Form Title Networks
Behavioral Health Release of Information Form - Sample  All networks
COB Questionnaire  All networks

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Network Participation and Provider Updates

Form Title Networks
Demographic Change Form  All networks
Provider Onboarding Form All networks

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Pharmacy

 

Form Title Networks
Refer to the Pharmacy Program section for more information. All networks
Uniform Prior Authorization Form Commercial only
Uniform Prior Authorization Form Medicaid only
Synagis Prior Authorization Form Medicaid only
Affordable Care Act (ACA) Copay Waiver Form  Commercial only
Affordable Care Act (ACA) Program Summary  Commercial only
Formulary Coverage Exception Form  Commercial only

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Preservice Review

Form Title Networks
AI/AN Limited Cost-Sharing Referral Form American Indian and Alaska Native
 Medicaid Prior Authorization Request Form Medicaid only 
 Recommended Clinical Review Request Form Commercial, non-HMO

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Wellness

Form Title Networks
Medicare Advantage Annual Wellness Visit Form Medicare Advantage plans

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