For Providers: Forms and Documents

Looking for the right form or document to help care for your patients? Find what you need to get your work done quickly.

Assessment forms

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Acute Inpatient Fax Assessment Form

Complete and fax this form for an acute inpatient assessment.

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Acute Rehabilitation and Skilled Nursing Facility Assessment Form for Blue Cross

Complete and fax this form for skilled nursing and acute rehabilitation assessment.

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LTACH and Skilled Nursing Facility Enhancement Assessment Form for Blue Cross

Complete and fax this form for commercial PPO LTACH and skilled nursing enhancement assessment.

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Medicare Plus Blue PPO Acute Inpatient Fax Assessment Form

Complete and fax this form for out of area Medicare Plus Blue PPO acute inpatient assessments.

Blue Cross Complete

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Blue Care Complete of Michigan Prescription Drug Program Overview

This document identifies the basic terms of drug coverage for Blue Cross Complete members.

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Blue Cross Complete Specialty Drug Guide

Use this guide to understand which specialty drugs are covered by Blue Cross Complete.

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Michigan Department of Community Health - Health Plan Carve-Out

This lists the medicines Medicaid pays for instead of Blue Cross Complete of Michigan.

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Blue Cross Complete Preferred Drug List

When prescribing medications for Blue Cross Complete members, please refer to this drug list.

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Blue Cross Complete Pharmacy Prior Authorization Guidelines

Refer to this list to see which drugs require prior authorization and what the criteria are for each drug.

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Blue Cross Complete Prior Authorization Request Form

Fill out this form to request prescription drug coverage for your patient.

Care management

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Learn about our care management and utilization management offerings and how they're covered.

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Physician Verification Form

This form is used with our wellness plans, like Healthy Blue Achieve, to request a medical waiver for a patient or update a patient's progress.

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High-intensity in-home care program FAQ

Answers frequently asked questions about the Landmark high-intensity in-home care program for members with Medicare Advantage plans.

Medical chart review reimbursement

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Ciox Medical Chart Review Reimbursement Form

If you've supplied our vendor, Ciox Health, with medical charts for Medicare Plus Blue PPO, you can request reimbursement with this form.

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Blue Cross HEDIS Medical Chart Review Reimbursement Form

If you've supplied medical records to a Blue Cross HEDIS clinical consultant performing HEDIS retrievals, you may request reimbursement with this form or through your HEDIS clinical consultant. We only reimburse for Blue Cross Medicare Plus Blue, Blue Cross Commercial PPO and Marketplace PPO members.

Medicare Advantage

View all our drugs lists along with guidelines for step therapy and prior authorization requests.

Learn about our enhanced benefit policies for Medicare Plus Blue℠ PPO plans for individuals and groups.

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Waiver of Liability

Medicare sometimes denies payment for certain health care services. If you're a non-contracted provider you can try to appeal a Medicare denial. As part of the process, you'll have to fill out the above form. You can find this and the other requirements for an appeal at the Centers for Medicare & Medicaid Services.

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Medicare Plus Blue PPO Provider Agreement

The Medicare Advantage PPO Provider Agreement includes a base agreement that applies to all providers.

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Medicare Plus Blue PPO Provider Agreement Practitioner Attachment

This document applies to practitioners participating in Medicare Plus Blue PPO.

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Medicare Plus Blue PPO Provider Agreement Hospital Attachment

This document applies to hospitals participating in Medicare Plus Blue PPO.

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Medicare Plus Blue PPO Provider Agreement Non-Hospital Attachment

This document applies to non-hospital facilities participating in Medicare Plus Blue PPO.

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Medicare Plus Blue PPO Provider Agreement Rural Facilities Attachment

This document applies to rural facilities participating in Medicare Plus Blue PPO.

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Medicare Plus Blue PPO Provider Agreement Federally Qualified Health Clinic Attachment

This document applies to federally qualified health clincics participating in Medicare Plus Blue PPO.

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End Stage Renal Disease Facility Medicare Plus Blue PPO Payment Rates

ESRD facilities should refer to this fee schedule when caring for a Medicare Plus Blue PPO patient. Member copayments and deductibles apply.

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Medicare Plus Blue PPO Enhanced Benefits Fee Schedule

To learn about reimbursement for enhanced benefits under Medicare Plus Blue PPO, refer to this fee schedule.

Advantasure Remote CDI Program for Medicare Plus Blue PPO

Blue Cross Blue Shield of Michigan has partnered with Advantasure in their Remote Clinical Documentation Improvement Program. This program helps providers make complete and accurate diagnoses of our Medicare Plus Blue PPO members.

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Advantasure Clinical Documentations Improvement Alert for Medicare Plus Blue PPO

Use this alert as a guide during the face-to-face or telehealth (audio and visual component) patient visit.

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Advantasure Remote CDI Completion Tips for Medicare Plus Blue PPO

This tip sheet can help you complete a CDI alert.

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Remote Clinical Documentation Improvement Program Participation and Fax Validation Form for Medicare Plus Blue PPO

Complete and fax this form to confirm your current information for the CDI program.

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Out-of-Area Providers: Advantasure® Remote CDI Program™ for Medicare Plus Blue PPO

Blue Cross Blue Shield of Michigan has partnered with Advantasure in their Remote Clinical Documentation Improvement Program. This program helps providers make complete and accurate diagnoses of our Medicare Advantage PPO members.

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Out-of-Area Providers: Advantasure Clinical Documentations Improvement Alert for Medicare Plus Blue PPO

Use this alert as a guide during the face-to-face or telehealth (audio and visual component) patient visit.

Pharmacy services

View all our drugs lists along with guidelines for step therapy and prior authorization requests.

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Specialty Drug Program Member Guide

Specialty drugs are prescription medications that require special handling, administration or monitoring. They may need special handling and monitoring.

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15-Day Specialty Drug Limitation Program

We limit certain specialty drugs to a 15-day supply limit to reduce copays and drug waste.

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Michigan Participating Commercial Retail Pharmacies

Here's all the participating pharmacies in Michigan.

If you need help with an Express Scripts issue, visit their resource center for answers.

Recredentialing

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Allied Provider Recredentialing Form

If you need to recredential as a clinical independent laboratory, durable medical equipment supplier, freestanding radiology center, Medicare-approved ambulatory surgical facility, Medicare-approved physiological laboratory or urgent care center, use this form.

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Facility Provider Recredentialing Form

All other hospitals and facility types can use this form to recredential.

Referral forms

Use e-referrals to complete referrals for any BCN patients.

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Dentist to Physician Referral Form

Dentists can use this form when they see a medical issue that needs a referral to a physician.

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Physician to Dentist Referral Form

Physicians can use this to refer a patient for a comprehensive oral assessment and dental treatment.

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UAW Trust PPO Program Referral Form

Use this form when you need to refer to a non-UAW Trust PPO participating practitioner, facility, ancillary provider or laboratory.

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U.P. Blue Referral Form

Only Michigan PPO providers for U.P. Blue Cross members can use this form. It can't be used by out-of-state providers.

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IBU PPO Out-of-State Exception Form

This is for referring patients with an individual plan who are out of state.

Supply forms

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Professional & Facility Supply Requisition Form

Fill this out to order general administrative materials you need when doing business with Blue Cross

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Physician Verification Form

This form is used with our wellness plans, like Healthy Blue Achieve, to request a medical waiver for a patient or update a patient's progress.