Provider Forms

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• Administrative
• Enrollment and Credentialing
• EDI 

Administrative

FORM	Purpose
BlueCard Appeal Form	To appeal a confirmed denial of benefits
Chiropractic Plan of Treatment Form	Prior approval for chiropractors
Claim Check Denial Form	To appeal a claim
CMS 1500	To file a claim
CMS 1500 Billing Instructions	CMS 1500 paper claim billing instructions
COB Questionnaire for BlueCard Members	To file COB info on BlueCard members.
Coordination of Benefits Questionnaire	When a patient is covered by more than one health plan
HCFA 1500	To file a claim
Inpatient Pre-certification Request Form	Inpatient pre-certification request form
Payment Inquiry Form	To inquire about a payment/claim
Prior Approval Request & Referral Authorization Form for Medical Services	Request for prior approval for procedures
Prior Approval Request Form for DME, Orthotics, and Prosthetics	Request for prior approval for DME
Prior Approval Forms (drug-specific) and Guidelines for Prescription Drugs	Rx Center
Provider Overpayment Form	When you detect an overpayment

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Enrollment & Credentialing

FORM	Purpose
CAQH Application for Credentialing	Paper application for providers who don't want to file electronically.
Enrollment/Change Form	- Adding a new provider, or creating a group - Open/Closing a patient panel - Making changes in address/phone/locations - Termination of provider
Practitioner Credentialing Rights	Provider rights during credentialing process.
W9	Used to report income to IRS.

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EDI

FORM	Purpose
EDI Enrollment Form	Provider and trading partners submit claims electronically and/or receive electronic RAs.
Companion Guide Updates	3/29/10 Updates to Companion Guides; including 835, 837 Institutional and 837 Professional.
835 Companion Guide	Guidelines for provider/clearing house on electronic 835 RAs.
837 Professional Companion Guide	Guide for submitting professional HCFA claims.
837 Institutional Companion Guide	Guide for submitting institutional UB claims.
SFTP User Guide	Guide for submitting electronic transactions.
Trading Partner Agreement - Direct	Agreement for direct electronic transactions for both parties BCBSVT and the provider.
Trading Partner Agreement - Indirect	Agreement for indirect electronic transactions for both parties, BCBSVT and the clearing house.

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