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Forms

Behavioral Health


FormDescription
Clinical Update Request Form  Request for clinical update on a member in the Focused Outpatient Management Program
Electroconvulsive Therapy Request  Request for review of medical necessity
Intensive Outpatient Program Request  Request for review of medical necessity
Outpatient Treatment Request  Request for outpatient behavioral health treatment
Professional Areas of Expertise Form  This form is required for all behavioral health professionals.
Facility Areas of Expertise Form  This form is required for all behavioral health facilities.
Psychological/Neuropsychological Testing Request  Request for review of medical necessity
Transitional Care Request-Behavioral Health  Request for BCBSNM members requiring ongoing care for an existing behavioral health condition


Claims


FormDescription
Claim Review Form  Use this form to request a review of a previously adjudicated claim.
CMS-1500 User Guide  This guide will help providers complete the CMS-1500 (08/05) form for patients with BCBSNM insurance.
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
Provider Request for Appeal on Behalf of a Medicaid Member  Request for an appeal on behalf of a member — for Blue Cross Community Centennial members
UB-04 User Guide  This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.


Electronic Commerce


FormDescription
Electronic Funds Transfer (EFT) Agreement  Use this form to enroll in EFT.
Electronic Remittance Advice (ERA) Enrollment Form  Use this form to enroll in ERA.


Medical Management


FormDescription
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
Catastrophic Petition Request  Use as a cover sheet when submitting catastrophic record documentation
Blue Cross Community Centennial Referral and Transition of Care Request  Use when a Medicaid member is changing level of care
Erythropoiesis – Stimulating Agents (ESA)  Request for ESA
Genetic Testing  Request for Tier 2 genetic tests
Hyperbaric Oxygen (HBO) Pressurization Form  Request for HBO pressurization treatment
Immunoglobulin Therapy Request Form  Request for IVIG treatment
PAVETTM Evaluation for Microprocessor Knee  Request authorization for prosthetics
Preauthorization Request  Use for services requiring preauthorization
Preauthorization Request for Blue Cross Community Centennial Members  Request authorizations for Blue Cross Community Centennial (Medicaid) members
Predetermination Request  Use for services requiring predetermination
Synagis Statement of Medical Necessity  This form is for the predetermination/authorization of the medication Synagis used in the prevention of respiratory syncytial virus.
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


Member/Patient


FormDescription
Dependent Student Medical Leave Certification Form  Allows dependent college students insured under their parent's policy to remain covered if they are required to take a medical leave of absence from school or make any other enrollment changes that might cause them to lose dependent student eligibility.
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.


Network


FormDescription
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


                 

Pharmacy


FormDescription
PrimeMail New Prescription Fax Order Form  Must be faxed from a physician's office
Drug Prior Authorization Request Form  Use for drugs requiring preauthorization
Fax this form to 505-816-3853.
Specialty Pharmacy Fax Form  Specialty pharmacy drugs fax form