New Physician Verification Form replaces Medical Waiver Request form

When members are enrolled in a Blues wellness plan and they’re unable to meet a required health measure or activity due to a medical condition, you may request a medical waiver on their behalf.

We’ve updated the medical waiver form to accommodate each wellness plan. The previous Medical Waiver Request form will no longer be accepted. When a medical waiver is appropriate, please complete the medical waiver portion of the new Physician Verification Form on the patient’s behalf. 

Similar to the old form, the new verification formis still a separate document from the qualification form. You can download it from web-DENIS by logging in to Provider Secured Services at bcbsm.com: 

• Visit bcbsm.com and log in as a provider.
• Click on Provider Publication and Resources.
• Click on Newsletters and Resources.
• Click on Physician Verification Form, located on the right side of the screen.

You also can download the Physician Verification Form from the provider section of our website:

• Visit bcbsm.com and select the Providers tab.
• Click on Quick Links.
• Click on Healthy Blue Achieve.
• Click on Physician Verification Form.

After you’ve completed the form, be sure to sign it and fax it to the number listed on the form by the date provided in your patient’s enrollment materials. Your patient may have alternative activities to complete. Please refer your patient to the enrollment materials for additional information.

Here’s a summary of how the new Physician Verification Form will apply to your patients in BCBSM’s two standard wellness products.

Healthy Blue Achieve^SM PPO
If your patient is enrolled in Healthy Blue Achieve, the Physician Verification Form can be used the following ways:

• To waive your patient from one or more health measure requirements. Healthy Blue Achieve members will be waived from the health measure you identify on the form and won’t be required to complete the respective alternative activity, such as the walking program, food journaling program or tobacco cessation program. Note: If your patient is pregnant or in hospice, use the Physician Verification Form to indicate this.
• To waive your patient from the walking requirement. If your patient doesn’t meet the body mass index target, and you feel they’re unable to meet the alternative walking requirement (walk an average of 5,000 steps per day), please complete the medical waiver section of the form to waive them from walking, and they’ll be required to participate in the food journaling program instead.
• To report newly met health measures to BCBSM after your patient’s initial qualification form has been submitted. If your patient originally missed one or more health measure requirements and they’ve been participating in an alternative wellness program, you can use the new health measure section of the form to notify us of their newly met health measure.

Healthy Blue Outcomes^SM
If your patient is enrolled in Healthy Blue Outcomes and you’re requesting a medical waiver on his or her behalf, please complete the medical waiver portion of the Physician Verification Form. Your patient will be required to complete the following alternate compliance activities:

• Two online digital coaching modules
• A follow-up visit with you to review the member’s health improvement plan, found on the back of the qualification form

You’ll also need to complete and fax the Medical Waiver Follow Up form indicating whether your patient has met expectations from the health improvement plan.

Members must complete these alternate compliance activities within 210 days of their benefit effective dates.

If you have questions about the new Physician Verification Form, contact your provider consultant.