Health Care Provider Forms

Note: Unless otherwise indicated, PRINT the document and submit as indicated on the form.

General

Forms	Description
American Indian/Alaska Native Limited Cost-Sharing Referral Form	Complete for AI/AN members when services are unavailable through I/T/U facilities, to get care from non I/T/U provider. Submit to fax or mailing address on form.
Behavioral Health Area of Expertise Form
Claim Review Note: Review each form to determine the appropriate form to use Additional Information Form Claim Review Form Corrected Claim Form	Fillable
Coordination of Benefits Form	Fillable - Submit form to: Blue Cross and Blue Shield of Texas PO Box 660044 Dallas, TX 75266-0044
Facility Coverage Letter	Interactive
Hemophilia Referral Fax	Interactive
Medicare Advantage Annual Wellness Visit Guide	Interactive
Medicare Advantage Annual Wellness Visit Form	Interactive
Medicare Advantage Offshore Attestation Form
Out-of-Network — Enrollee Notification Form for Regulated Business (Use this form if "TDI" is on member's ID card)
Out-of-Network — Enrollee Notification Form for Non-Regulated Business (Use this form if "TDI” is not on member's ID card)
PPO Notification for non pre-cert surgeries per Texas Administrative Code 3.3703	Fillable
Prior Authorization - TDI Standard Health Care Services Prior Authorization Form	Fillable
Prior Authorization - TDI Standard Prescription Drugs	Fillable
Provider Check and Voucher Request Form	Fillable
Provider Refund	Fillable
Recommended Clinical Review Form – Outpatient Services	Fillable
Room Rate Update Notification	Fillable
Request for Continued Access to Providers (formerly Transitional Care Request)	Fillable
Verification Of Benefits Processing and Request Form	Verification of Benefits Form Interactive

Medical Policy Forms (Note: May be used as a supplement to medical record documentation)

Form Title	Description
Bariatric Surgery	Interactive
Cranial Remolding Orthosis Device	Interactive
Genetic Testing	Instructions Fillable
Hyperbaric Oxygen Pressurization	Interactive
Oncotype DX	Interactive
Varicose Vein Management	Interactive
Wheelchair Medical Necessity and Home Evaluation Verification	Interactive

Behavioral Health/Mental Health Forms for ERS Participants

Form Title	Description
Mental Health Froms for Employees Retirement System of Texas (ERS)	Select Link for list of forms

Behavioral Health/Mental Health Forms for TRS Participants

Form Title	Description
Behavioral Health Forms for Teacher Retirement System of Texas	Select Link for list of forms

Behavioral Health for Texas Medicaid Plans

Texas Medicaid Behavioral Health forms

Behavioral Health for Other BCBSTX Plans

(Note: for ERS or TRS participants or Medicaid Members refer to specific form links above)

Form Title

Applied Behavior Analysis forms:

Behavioral Health Discharge Clinical Form

Biofeedback - Submit Recommended Clinical Review Form and Fax to 1-877-361-7646

Coordination of Care

Electroconvulsive Therapy Request

Intensive Outpatient Program Request

Post Service Review Request Form

Psychological/Neuropsychological Testing Request

Transcranial Magnetic Stimulation Request

Therapeutic Behavioral On-site Service Request

Request for Continued Access to Providers

Pharmacy

Form Title	Description
Express Scripts^® Pharmacy Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions	Fax forms must be faxed from a physician's office
Accredo Specialty Pharmacy General Use Fax Form	Specialty pharmacy drugs fax form for general use
Accredo Specialty Pharmacy Referral Forms by Therapy	Specialty pharmacy drugs fax form by drug therapy
Affordable Care Act Copay Waiver Form and Program Summary	Request $0 member cost share for preventive drug products not covered on a BCBSTX commercial plan drug list. Member’s physician must fax the form.
Formulary Coverage Exception Form	Request coverage for drug products not covered on a BCBSTX commercial plan drug list
Prior Authorization Standard Prescription Drugs	Fillable
Quantity Limit Override Request	Request to override the dispensing/quantity limit
Topical Verapamil Override Request Specialty pharmacy drugs fax form for general use