Forms



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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FormDescription

•Applied Behavior Analysis(ABA)Initial Treatment Request (ITR) forms:


Applied Behavior Analysis (ABA) Managed Care/Concurrent Review Form 

 

Centennial Care Concurrent Clinical Review Form PDF Document This form is required for request of clinical information for an concurrent clinical review
Centennial Care Discharge Clinical Notification Form PDF Document This form is required when informing BCBSNM of discharge information
Centennial Care Fax Cover Sheet Clinical Notification Form PDF Document This form is required to be submitted with a request of clinical information for any review
Centennial Care Initial Clinical Review Form PDF Document This form is required for request of clinical information for an initial clinical review
Centennial Care Retrospective Clinical Review Notification Form PDF Document This form is required for request of clinical information for a retrospective clinical review
Clinical Update Request Form PDF Document Request for clinical update on a member in the Focused Outpatient Management Program
Coordination of Care Form PDF Document Use to provide member treatment information to or from another treating provider
Electroconvulsive Therapy Request PDF Document Request for review of medical necessity
Intensive Outpatient Program Request PDF Document Request for review of medical necessity
Outpatient Treatment Request PDF Document Request for outpatient behavioral health treatment for Medicaid members.
Professional Areas of Expertise Form PDF Document This form is required for all behavioral health professionals.
Facility Areas of Expertise Form PDF Document This form is required for all behavioral health facilities.
Psychological/Neuropsychological Testing Request PDF Document Request for review of medical necessity
Repetitive Transcranial Magnetic Stimulation (rTMS) Form  PDF Document Request for preauthorization
Transitional Care Request-Behavioral Health PDF Document Request for BCBSNM members requiring ongoing care for an existing behavioral health condition

FormDescription
Check and Voucher Request Form PDF Document Effective July 11, 2016, duplicate copies of PCS vouchers may no longer be requested using this form.
Claim Review Form PDF Document Use this form to request a review of a previously adjudicated claim.
Additional Information Claim Form  PDF Document Use this form to submit requested additional information.
Corrected Claim Form  PDF Document 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 PDF Document This form is only to be used for review of a delay in claim reimbursement when provider credentialing is simultaneously delayed.
CMS-1500 User Guide PDF Document This guide will help providers complete the CMS-1500 form.
Coordination of Benefits PDF Document To be completed by the member if enrolled with another carrier
Medicare Reconsideration Form  PDF Document 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 PDF Document 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 PDF Document Request for an appeal on behalf of a member — for commercial members
Provider Request for Appeal on Behalf of a Medicaid Member PDF Document Request for an appeal on behalf of a member — for Blue Cross Community Centennial members
UB-04 User Guide PDF Document This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.

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

FormDescription
Blue Cross Community Centennial Nursing Facility Level of Care (NFLOC) Reconsideration Form PDF Document Providers who disagree with a NFLOC determination can request reconsideration.
Blue Cross Community Centennial Notification of Birth form PDF Document 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 PDF Document Use as a cover sheet when submitting catastrophic record documentation
Blue Cross Community Centennial Referral and Transition of Care Request PDF Document Use when a Medicaid member is changing level of care
Erythropoiesis – Stimulating Agents (ESA) PDF Document Request for ESA
Genetic Testing PDF Document Request for Tier 2 genetic tests
Hyperbaric Oxygen (HBO) Pressurization Form PDF Document Request for HBO pressurization treatment
Immunoglobulin Therapy Request Form PDF Document Request for IVIG treatment
MAD 062 Personal Care Transfer-Closure Form PDF Document Request for Personal Care Service transfer/closure.
PAVETTM Evaluation for Microprocessor Knee PDF Document Request authorization for prosthetics
Preauthorization Request PDF Document Use for services requiring preauthorization
Preauthorization Request for Blue Cross Community Centennial Members PDF Document Request authorizations for Blue Cross Community Centennial (Medicaid) members
Predetermination Request PDF Document Use for services requiring predetermination
Proton Beam Radiation Therapy Physician Worksheet  PDF Document Request benefit predetermination for proton beam radiation therapy
Synagis Statement of Medical Necessity PDF Document This form is for the predetermination/authorization of the medication Synagis used in the prevention of respiratory syncytial virus.
Transitional Care Request PDF Document Request for BCBSNM members requiring ongoing care for an existing medical condition.
Wheelchair Medical Necessity and Home Evaluation Verification PDF Document Request for manual and power wheelchairs, scooters and other power-operated vehicles

FormDescription
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.

FormDescription
Applications to join the BCBSNM network PDF Document Complete the appropriate form(s) as described.
Fee Schedule Request PDF Document Request a copy of the CPT fee schedule.
Provider Disclosure Form PDF Document 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 PDF Document 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 PDF Document Request to establish a new record or revise an existing record for a non-contracted professional provider
W-9 Form PDF Document Request for taxpayer identification number and certification

FormDescription
PrimeMail New Prescription Fax Order Form PDF Document Must be faxed from a physician's office
Drug Prior Authorization Request Form (Commercial plans) PDF Document Use for drugs requiring preauthorization under BCBSNM commercial plans
fax to 877-243-6930
Drug Prior Authorization Request Form (Medicaid) PDF Document Use for drugs requiring preauthorization under the Blue Cross Community Centennial plan - the prescribing physician will need to fill out the form, sign it and fax to 877-243-6930.
Specialty Pharmacy Fax Form PDF Document Specialty pharmacy drugs fax form

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