Provider forms and documents

Accepting New Patients Verification

In order to help our members find BCBSND participating providers that are accepting new patients, we are asking you to assist us with keeping our provider directory up to date. If you have had a recent change in whether or not you are accepting new patients at any location, please complete the form below and we will update your file.

Accepting New Patients Update Form

Appeals

Appeal Form (Please note: The appeal form should not be used to submit a claim correction or as a venue for submitting medical records or EOBs.)

Authorized referral

Please note: Submit through the Availity portal on the Referrals page

Claims processing

Advance Member Notice
Medical Records Submission Form
Request for Independent External Review
SIU Institutional/DRG Adjustment Form
SIU Professional Adjustment Form

Legacy Institutional Claim Adjustment – removed June 1, 2021
Legacy Professional Claim Adjustment – removed June 1, 2021

Please note: To request a copy of the Legacy claims adjustment forms, contact the Provider Service Center at 1‑800‑368‑2312.

Use the Legacy adjustment forms to adjust a claim that processed in the BCBSND legacy system. Claim adjustment is the appropriate process for the following members:

1. Host (out-of-area) members with a date of service (DOS) prior to July 1, 2018;
2. FEP members (prefix of R) with DOS prior to September 1, 2018; or
3. BCBSND members with any of the following prefixes: BSB, DDU, DEW, OTO, RDO, SHV, THI, TNT, USZ, YQA, YQB, YQC, YQE, YQG, YQI, YQJ, YQP, YQQ or YQU with a DOS prior to January 1, 2019.

Use the claim correction process outlined in the provider manual for all other claim corrections. 

Comprehensive orthodontic treatment plan

Participation and credentialing

 

The following forms are located in Availity Payer Spaces under the Resources tab:

  • Change of Tax ID
  • Provider Directory Maintenance
  • Update Provider Information
  • New Location / Business Relationship

Electronic Remit and EFT requests can be submitted through Availity under My Providers, then Enrollment Center.

Pharmacy

Retail Pharmacy Forms

Coverage Exception
Pharmacy Coverage Exception Form – External Review
Patient Protection and Affordable Care Act (PPACA) Preventive Copay Waiver Form

If your benefit plan is subject to PPACA preventive services, you may request a Copay Waiver for a product within a preventive service class that is not a designated preventive service product.

Precertification