If you plan to get care from a provider outside North Dakota and that is not contracted within the Blue Cross Blue Shield of North Dakota network or another state's Blue Cross Blue Shield (BCBSND) network, you may need a waiver before services are covered.
This helps make sure care is provided by qualified facilities and protects members from billing fraud.
This form is only to be utilized for individual metallic (bronze, silver, or gold) plan members who are seeking non‑urgent care from an out‑of‑state provider who isn’t in the BCBSND or another state's Blue Cross Blue Shield network. Members can utilize their benefit plan book to confirm what plan type they are on. If you have coverage through your employer or have a non-metallic product, you do not need to fill out this form.
Utilize the Find a Doctor tool to see if you can get care from participating providers in your network to lower your cost.
Submit your request at least 15 days before your appointment for review.
This form should not be filled out by providers. This form is required to be filled out by the member or their approved authorized representative (complete and correct authorization form needed).
An approved waiver would be required if all in the following example are true:
The services and code have been identified through BCBSND's fraud prevention review as requiring a waiver before coverage will be considered.
