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• Administrative
• Enrollment and Credentialing 

Updated: 04-26-2013

Administrative

FORM	Purpose
BlueCard Appeal Form	To appeal a confirmed denial of benefits
Chiropractic Plan of Treatment Form	Prior approval for chiropractors
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
Inpatient Rehabilitation Re-certification Form	Inpatient Rehabilitation Re-certification 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 and 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
Area of Expertise Form	Mental health and substance abuse clinicians must use this form to identify their area of expertise for marketing in both the on line and paper directories.
CAQH Application for Credentialing	Paper application for providers who don't want to file electronically.
Facility Credentialing	Defines the requirements for facilities
Provider Enrollment/Change Form (PECF)	- Add a new provider to the practice - Open/Close a patient panel - Changing address location - Termination of a provider - Changing a providers name
Group Practice Enrollment/Change Form (GPECF)	- Enrolling a new group practice - Enrolling an independent provider in private practice - Changing a Tax ID - Changing a NPI - Changing billing/physical/correspondence addresses - Changing the group name
Practitioner Credentialing Rights	Provider rights during credentialing process.
W9	Used to report income to IRS.

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