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Coordination of Benefits

• Coordination of Benefits/Blue Cross and Blue Shield of Alabama is Host Plan

Dental

• Dental Provider Application
• Out-of-State Dental
• Notification of Noncovered Dental Services

Provider Enrollment

• See Provider Maintenance Page for Forms
• Preferred Radiology Provider Program New Physician Notification

Medical

• Chiropractic Visits Certification Form
• Continuity of Care Request Form
• Member Management Referral Form
• DME Certification Form
• HIPAA Privacy and Non-Filed Claims
• Medical Necessity for Out-of-State Providers for Bariatric Surgery
• Noncovered Services Statement
• Noncovered Services Statement for Preferred Medical Doctors
• Outpatient Predetermination Request Cover Sheet
• Personal Choice Network Retro-Referral Form (for the Personal Choice Network ONLY)
• Provider Appeals
• Referral Form for Indian Health Services
• Voluntary Overpayment Return

Medical – Blue Advantage

• Blue Advantage Therapy Precertification Form

Precertification

• Chiropractic Certification Form
• DME Certificate of Medical Necessity
• FEP Hospice Request for Certification
• Home Health Request for Certification
• Hospice Certification Form
• LTAC Preadmission Evaluation Form
• Therapy Precertification - Blue Advantage
• Therapy Precertification - Occupational
• Therapy Precertification - Physical
• Therapy Precertification - Speech

Psychiatric

• Authorization for Disclosure of Mental Health Clinical Information
• Behavioral Health Substance Abuse Certification
• Behavioral Health Substance Abuse Continued Stay Review Form
• Behavioral Health Case Management Prescreening

Blue Advantage Drug Prior Authorization

• Blue Advantage Physician Drug Authorization Request Form
• Blue Advantage Drug Coverage Determination, Formulary or Tier Exception Drug Authorization Forms, Quantity Limit Drug Authorization Forms and Step Therapy Drug Authorization Forms

BlueRx Drug Prior Authorization

• BlueRx Physician Drug Authorization Request Form
• BlueRx Drugs Drug Coverage Determination, Formulary or Tier Exception Drug Authorization Forms, Quantity Limit Drug Authorization Form and Step Therapy Drug Authorization Forms