• Language Assistance
  • espanol En español
Mobile Menu Icon
Logo
Provider Medicaid
Logo
Provider Medicaid
  • home
  • Network Participation
    • Network Participation
    • Attestation and Agreement
    • Credentialing and Recredentialing
    • Provider and Pharmacy Directories
  • Claims & Eligibility
    • Claims
    • Eligibility
    • Utilization Management (Prior Authorizations)
    • Long Term Services and Support (LTSS)
    • Provider Administered Drugs
    • Referral Requirements
    • STAR Kids Referral and Authorization Process
    • Electronic & Paper Submission Edits
  • Education & Reference
    • Education and Reference
    • Blue Review
    • Education Materials
    • Electronic Visit Verification (EVV)
    • Forms
    • News
    • Provider Training
    • Texas Health Steps (THSteps) Toolkit
    • Value-Added Services for STAR, CHIP and STAR Kids
    • Medicaid Provider Information on COVID-19 Coverage
  • Clinical Resources
    • Clinical Resources
    • Behavioral Health
    • Clinical Practice Forms
    • Early Childhood Intervention
    • Medical Policies
    • Vision
    • Quality Improvements (QI) Toolkits and Tip Sheets
  • Pharmacy
    • Pharmacy
    • Home Delivery Pharmacy (Mail-Order Pharmacy)
    • Benefits and Claims
    • Pharmacy Clinical Edits
    • Preferred Drug List
    • Medicaid (STAR) and CHIP Prior Authorization Forms
    • STAR Kids Prior Authorization Forms
  • Contact Us
  • Sign Up or Log In

  • Contact Us
  • Sign Up or Login
Blue Access for Members
blue access for members log in
Sign Up or Log In
Blue Access for Members
Sign Up or Log In

Forms

Prior Authorization

Children and Pregnant Women (CPW) Referral and Intake Form

Medicaid (STAR) and CHIP Prior Authorization Forms

 Medical Record Retrieval and Electronic Medical Record Questionnaire

Private Duty Nurse (PDN) Initial Request Long Term Services and Support (LTSS) Authorization Request Checklist

Private Duty Nurse (PDN) Recertification and Revision Request Long Term Services and Support (LTSS) Authorization Request Checklist

Private Pay Agreement

Request for Prior Authorization – Acute

Request for Prior Authorizatioin - Long Term Services and Support (LTSS)

STAR Kids Prior Authorization Form

Texas Standard Prior Authorization of Health Care Services Form

Behavioral Health

Applied Behavioral Analysis Form

Applied Behavioral Health Prior Authorization Requirement Checklist 

Behavioral Health Coordination of Care Form

Behavioral Health Prior Authorization Checklist

Substance Use Residential Services Form

Other

Access Appointment Availability OBGYN

Access Appointment Availability PCP

Access Appointment Availability Specialist

Attestation Form for Collaborative Care Model (CoCM) in Texas Medicaid

Claim Status Request Form

DME Request for Claim Status Form

DME Review Request Form

Fraud Referral

Migrant Farmworker Questionnaire

Outreach Request Form

Provider Appeal Request Form

Provider Compliance Challenges with Prenatal Appointment Availability

Provider Refund Form

Rate Enhancement for Attendant Compensation Form

Reconsideration Request Form

 

 
  • Legal and Privacy
  • Non-Discrimination Notice

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association


© Copyright 2022 Health Care Service Corporation. All Rights Reserved.

PDF File is in portable document format (PDF). To view this file, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader® which has a built-in reader. Other Adobe accessibility tools and information can be downloaded at https://access.adobe.com

External link You are leaving this website/app (“site”). This new site may be offered by a vendor or an independent third party. The site may also contain non-Medicare related information. In addition, some sites may require you to agree to their terms of use and privacy policy.

  • Home
  • Network Participation
    • Network Participation
    • Attestation and Agreement
    • Credentialing and Recredentialing
    • Provider and Pharmacy Directories
  • Claims & Eligibility
    • Claims
    • Eligibility
    • Utilization Management (Prior Authorizations)
    • Long Term Services and Support (LTSS)
    • Provider Administered Drugs
    • Referral Requirements
    • STAR Kids Referral and Authorization Process
    • Electronic & Paper Submission Edits
  • Education & Reference
    • Education and Reference
    • Blue Review
    • Education Materials
    • Electronic Visit Verification (EVV)
    • Forms
    • News
    • Provider Training
    • Texas Health Steps (THSteps) Toolkit
    • Value-Added Services for STAR, CHIP and STAR Kids
    • Medicaid Provider Information on COVID-19 Coverage
    • TMHP Demographic Information Updates
    • Provider Advisory Group
    • 24 Hour Nurse Hotline
  • Clinical Resources
    • Clinical Resources
    • Behavioral Health
    • Clinical Practice Forms
    • Early Childhood Intervention
    • Medical Policies
    • Vision
    • Quality Improvements (QI) Toolkits and Tip Sheets
  • Pharmacy
    • Pharmacy
    • Home Delivery Pharmacy (Mail-Order Pharmacy)
    • Benefits and Claims
    • Pharmacy Clinical Edits
    • Preferred Drug List
    • Medicaid (STAR) and CHIP Prior Authorization Forms
    • STAR Kids Prior Authorization Forms