Education & Reference
Clinical Resources
Standards & Requirements
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.
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| Form | Description |
| Blue Cross Community Centennial BH ABA Clinical Review Form Stage | This form is required to be submitted for ABA Stage 3 planning and treatment |
| Centennial Care Specialty Provider Clinical Review Form ABA | This form is required to be submitted for ABA Specialty Care Provider Prior Authorization |
| Centennial Care Fax Cover Sheet Clinical Notification Form | This form is required to be submitted with a request of clinical information for any review |
| Centennial Care Psychological or Neuropsychological Testing Request Form | Request for review of medical necessity |
| Electroconvulsive Therapy Request | Request for review of medical necessity |
| Repetitive Transcranial Magnetic Stimulation (rTMS) Form | Request for preauthorization |
| Form | Description |
|---|---|
Request for review of medical necessity |
|
Request for review of medical necessity |
|
| Medicare – Repetitive Transcranial Magnetic Stimulation (rTMS) Form | Request for prior authorization |
| Form | Description |
|---|---|
• Applied Behavior Analysis (ABA) Clinical Service Request Form • Applied Behavior Analysis (ABA) Initial Assessment Request |
|
| Behavioral Health Discharge Clinical Form | Use this form to provide needed information for a Blue Cross and Blue Shield of New Mexico (BCBSNM) member recently discharged from Behavioral Health treatment |
| Behavioral Health Recommended Clinical Review | Fax to 877-361-7659 for biofeedback requests |
| Coordination of Care Form | Use to provide member treatment information to or from another treating provider |
| Electroconvulsive Therapy Request | Request for review of medical necessity |
| Facility Areas of Expertise Form | This form is required for all behavioral health facilities. |
| Intensive Outpatient Program Request | Request for review of medical necessity |
| NM Uniform Prior Authorization Form | Use for services requiring prior authorization |
| Professional Areas of Expertise Form | This form is required for all behavioral health professionals |
| Psychological/Neuropsychological Testing Request | Request for review of medical necessity |
| Repetitive Transcranial Magnetic Stimulation (rTMS) Form | Request for prior authorization |
| Supervision via Telehealth Request & Attestation | Request for telehealth services for ABA |
| Therapeutic Behavioral On-Site Services Request | Use this form when requesting Therapeutic Behavioral On-Site Services |
| Transitional Care Request – Behavioral Health |
This form must be completed by the member and/or provider for any BCBSNM member receiving ongoing behavioral health care with an out-of-network provider |
Claims
| Form | Description |
| CMS-1500 User Guide | This guide will help providers complete the CMS-1500 form |
| Provider Request for Appeal on Behalf of a Medicaid Member | Request for an appeal on behalf of a Blue Cross Community Centennial member |
| Provider Self-Identified Overpayment Form | Use this form to self-report overpayments identified by the provider |
| Provider Form for Transportation Attendant | Use this form for members who want to bring someone with them on a trip to/from an appointment. You will need to confirm it is medically necessary for an escort to go with the member. This form must be sent in before a member arranges to bring someone with them. Please fax the completed form to 1-866-402-0522. |
Medical Management
| Form | Description |
| Annual Centennial Care Agency Based Community Benefit Provider Attestation Form - CMS Final Rule for HCBS | CMS Final Rule for Home and Community Based Services (HCBS) Screening and Attestation Form |
| Blue Cross Community Centennial Nursing Facility Level of Care (NFLOC) Reconsideration Form | Providers who disagree with a NFLOC determination can request reconsideration |
| Blue Cross Community Centennial Notification of Birth form | Form and instructions to notify the County Income Support Division office of the birth of a child to a New Mexico Medicaid eligible mother |
| Blue Cross Community Centennial Referral and Transition of Care Request | Use when a Medicaid member is changing level of care |
| NM Uniform Prior Authorization Form for Blue Cross Community Centennial (Including Drug Prior Authorization Requests) | Request authorizations for Blue Cross Community Centennial (Medicaid) members, including for drugs requiring preauthorization under the Blue Cross Community Centennial plan |
| Form | Description |
|---|---|
| Check and Voucher Request Form | Effective July 11, 2016, duplicate copies of PCS vouchers may no longer be requested using this form. |
| Claim Review Form | Use this form to request a review of a previously adjudicated claim. Do Not Use this form to appeal on behalf of a member. |
| Additional Information Claim Form | Use this form to submit requested additional information. |
| Corrected Claim Form | Use this form to request corrections to a previously adjudicated claim when you are unable to submit the corrections electronically. |
| Credentialing and Reimbursement Dispute Form | This form is only to be used for review of a delay in claim reimbursement when provider credentialing is simultaneously delayed. |
| Coordination of Benefits | To be completed by the member if enrolled with another carrier |
| Medicare Reconsideration Form | Use this form to submit a request for an adjustment for a claim that was excluded from crossing over to BCBSNM due to the Medicare mass adjustment process, as related to 2010 Medicare physician fee schedule changes and certain provisions of the affordable care act. |
| Provider Refund Form | Use this form when a refund is due to BCBSNM and you would like to send in a voluntary check for the refund. |
| Provider Request for Appeal on Behalf of a Member | Request for an appeal on behalf of a member — for commercial members |
| UB-04 User Guide | This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage. |
| Form | Description |
|---|---|
| Availity.com |
Enroll online for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) via Availity® – learn more! |
| Form | Description |
|---|---|
| Medicare Annual Wellness Visit Form | This form and its accompanying Medicare Advantage Annual Wellness Visit Guide may be helpful to follow during our Medicare members' wellness visits. |
| Catastrophic Petition Request | Use as a cover sheet when submitting catastrophic record documentation |
| Genetic Testing | Request for Tier 2 genetic tests |
| Hyperbaric Oxygen (HBO) Pressurization Form | Request for HBO pressurization treatment |
| MAD 062 Personal Care Transfer-Closure Form | Request for Personal Care Service transfer/closure. |
| NM Uniform Prior Authorization Form | Use for services requiring prior authorization. |
| Proton Beam Radiation Therapy Physician Worksheet | Request benefit predetermination for proton beam radiation therapy |
| Recommended Clinical Review (Predetermination) Request | Use for services requiring recommended clinical review (predetermination) |
| Transitional Care Request | Request for BCBSNM members requiring ongoing care for an existing medical condition. |
| Wheelchair Medical Necessity and Home Evaluation Verification | Request for manual and power wheelchairs, scooters and other power-operated vehicles |
| Form | Description |
|---|---|
| Standard Authorization Form and other HIPAA Privacy Forms for Medicaid Members | Blue Cross Community Centennial members can use these forms to provide authorization for BCBSNM to share Protected Health Information (PHI) or make other requests related to their privacy. |
| Standard Authorization Form and other HIPAA Privacy Forms | All other BCBSNM plan members can use these forms to provide authorization for BCBSNM to share Protected Health Information (PHI) or make other requests related to their privacy. |
| Form | Description |
|---|---|
| Applications to join the BCBSNM network | Complete the appropriate form(s) as described. |
| Fee Schedule Request | Request a copy of the CPT fee schedule. |
| Provider Disclosure Form | Complete before entering into or renewing a Medicaid provider contract, within 35 days after any change in ownership of the disclosing provider, or upon request as applicable. |
| Request to Establish or Revise a Non-Contracted Facility Record | Request to establish a new record or revise an existing record for a non-contracted facility provider |
| Request to Establish or Revise a Non-Contracted Provider Record | Request to establish a new record or revise an existing record for a non-contracted professional provider |
| W-9 Form | Request for taxpayer identification number and certification |
| 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 sent 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 |
| NM Uniform Prior Authorization Form | Use for drugs requiring preauthorization under BCBSNM commercial plans fax to 877-243-6930 |
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