The Record - for physicians and other health care providers to share with their office staffs Forward to a friend  |  Subscribe  |  The Record Archive  |  Contacts  |  bcbsm.com  |  Print this article
July 2014

The revised 2014 qualification form is here

In response to questions and feedback we’ve received about the 2014 qualification form, Blue Cross Blue Shield of Michigan has revised the form to clarify the instructions.

As of July 1, 2014, there’s a separate qualification form for members with health plans that require cotinine testing to confirm non-tobacco use. This form should be used for members in the Healthy Blue Achieve® or Healthy Blue Outcomes® plans. Members with health plans that don’t require the cotinine test will use the new standard form.

The forms are marked with clear titles for easy identification:

  • Qualification Form — Standard
  • Qualification Form — Cotinine Test is Required 

The member welcome packet, in addition to the member and provider portals, contain updated instructions for completing the new forms.

Remember that members in the Healthy Blue Achieve and Healthy Blue Outcome plans should receive a cotinine test to confirm non-tobacco use. Cotinine tests are typically not a covered benefit, so please don’t order the test for a patient who doesn’t need it.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.