Documents & Forms

For your convenience, we've put these commonly used documents together in one place. You'll also find news and updates for all lines of business. Start by choosing your patient's network listed below.

Commercial

Commercial networks include BlueNetwork P^SM & BlueNetwork S^SM

Administration Manuals
These manuals are your source for important information about our policies and procedures.
Commercial Provider Administration Manual
Provider Quick Reference Guide

Medicare Advantage

Medicare Advantage networks include BlueAdvantage (PPO)^SM, BlueEssential (HMO SNP)^SM & BlueElite^SM

Authorizations & Appeals
Forms and information to help you request prior authorization or file an appeal.
Appeals
Non-Contract Provider Appeal Form for BlueAdvantage Claims
Provider Reconsideration Form
Provider Appeal Form (Claim Reconsideration Appeal)
Utilization Management Appeal Form
Provider BlueCard Claim Appeal Form
Authorizations
2026 Special Supplemental Benefit for the Chronically Ill Attestation Form
BlueAdvantage Total Heart & Diabetes Provider Attestation Form
Care Management Contact Information
Claim Status Check Form
CMS Inpatient Only List
Detailed Notice of Discharge
Durable Medical Equipment (DME) Authorization Request Form
Home Health Outpatient Therapies Service Request Form
Inpatient/Outpatient Service Request Form
Master Prior Authorization List
Medicare Home Health Face-to-Face Encounter
Medical Policy Appeals Process
MSK Injection Authorization Request Form
Notice of Medicare Non Coverage
PPO fax cover sheet
Predetermination Authorization Request Form
Provider-Administered Specialty Pharmacy List
Provider Reference Guide / Prior Authorization List
Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
Waiver of Liability Statement

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Behavioral Health
Forms and information about behavioral health services for your patients
Behavioral Health Out of Network Request Form
Behavioral Health Outpatient Request Form
Behavioral Health Provider Discharge Form
Mental Health Inpatient Request Form
Psychiatric Residential Treatment Request Form
Psychological/Neuropsychological Testing Form

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Pharmacies & Prescriptions
Forms and information about pharmacy services and prescriptions for your patients.
2026 BlueAdvantage and Total Heart & Diabetes Medication List (Formulary) (Updated: 6/1/2026)
2026 BlueAdvantage Extra and Total Heart & Diabetes Plus Medication List (Formulary) (Updated: 6/1/2026)
2026 Medicare Part D Prior Authorization Criteria (Updated: 6/1/2026)
Medicare Part B Prior Authorization Criteria
Controlled Substance Prescribing
Immunizing Pharmacist Vaccine Code List
Part B Step Therapy Reference Guide (Updated: 5/1/2026)
Part D - Prescription Hierarchical Condition Categories (RxHCC)
Prescription Mail Service Order Form
Provider-Administered Specialty Medication List (Updated: 6/1/2026)
Provider-Administered Medication Authorization Form

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Quality Care Initiatives
Information to help you maximize your performance in our quality programs.
4 STAR and Above Providers
Cognitive Assessment Tool
Diabetes Prevention Program
Depression Screening Tool
Fall Risk Assessment Tool
PCP Change Form
Physician Now FAQs
Quality+ Partnerships Program Guide
Quality+ Partnership Program Measures
Risk Adjustment Program

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Medicare with Medicaid (BlueCare Plus℠)

Authorizations & Appeals
Forms and information to help you request prior authorization or file an appeal.
Appeals
Non-Contract Provider Appeal Form for BlueCare Plus Claims
Provider Reconsideration Form
Provider Appeal Form (Claim Reconsideration Appeal)
Provider BlueCard Claim Appeal Form
Authorizations
Advance Determination Decision
Advance Determination Request
Care Management Contact Information
Certificate of Medical Necessity for Abortion Form
Cite Guideline Transparency
Consent for Sterilization Form
Durable Medical Equipment (DME) Intake Fax Form
High Tech Imaging C Code Crosswalk Reference Guide
High Tech Imaging Codes Requiring Authorization
Home Health Missed Visit Form
Inpatient/Outpatient Services Request Form
Instructions for completing Certificate of Medical Necessity for Abortion
Instructions for completing Consent for Sterilization Form
Medical Policy Appeals Process
MSK Procedure/Pain Management Codes
Private Duty Nursing/Home Health Plan of Care
Private Duty Nursing Home Plan of Care Agreement
Provider-Administered Specialty Medication List
Recertification Member/Caregiver Training Checklist
Skilled Nursing Facility Rehab Form
Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
Waiver of Liability Statement

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Behavioral Health
Forms and information about behavioral health services for your patients
Applied Behavioral Analysis (ABA) Referral Form
Applied Behavioral Analysis (ABA) Request Form
Behavioral Health Out of Network Request Form
Behavioral Health Outpatient Request Form
Behavioral Health Provider Discharge Form
Mental Health Inpatient Request Form
Provider Initiated Notice Form
Psychiatric Residential Treatment Request Form
Psychological/Neuropsychological Testing Form
Same Day Notice Form

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Pharmacies & Prescriptions
Forms and information about pharmacy services and prescriptions for your patients.
2026 BlueCare Plus & BlueCare Plus Choice Medication List (Formulary) (Updated: 6/1/2026)
2026 BlueCare Plus Select Medication List (Formulary) (Updated: 6/1/2026)
Medicare Part B Prior Authorization Criteria
Provider-Administered Specialty Medication List (Updated: 6/1/2026)
Provider-Administered Medication Authorization Form
Controlled Substance Prescribing
Part B Step Therapy Reference Guide (Updated: 5/1/2026)

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Quality Care Initiatives
Information to help you maximize your performance in our quality programs.
Medicare Advantage Diabetes Prevention Program
Quality+ Partnerships Program Overview/Measures

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Dental

Dental Resources

These documents contain information about your benefits, network and coverage.

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Enrollment

For support with Enrollment, Contracting, Credentialing or updating Provider information.

Contracting and Credentialing

These documents contain information about your benefits, network and coverage.

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Technical Support

For eBusiness support through the BlueCross secure website and all electronic data interchange (EDI) transactions.

Technical Support/ eBusiness Information

These documents contain information about your benefits, network and coverage.

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News and Updates

Announcements & Notices
Details about new programs and changes to our procedures and guidelines.
Count it! Lock it! Drop it! Provider Flyer
Provider Stability Act: Senate Bill No. 437
Current BlueAlert
Medicare Outpatient Observation Notice

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Archive
This section houses archived provider newsletters, code edits and code updates. These materials are provided for historical reference and may no longer reflect current guidance.
BlueAlert Newsletters
December 2025 BlueAlert
November 2025 BlueAlert
October 2025 BlueAlert
September 2025 BlueAlert
August 2025 BlueAlert
July 2025 BlueAlert
June 2025 BlueAlert
May 2025 BlueAlert
April 2025 BlueAlert
March 2025 BlueAlert
February 2025 BlueAlert
January 2025 BlueAlert
December 2024 BlueAlert
November 2024 BlueAlert
October 2024 BlueAlert
September 2024 BlueAlert
August 2024 BlueAlert
July 2024 BlueAlert
June 2024 BlueAlert
May 2024 BlueAlert
April 2024 BlueAlert
March 2024 BlueAlert
February 2024 BlueAlert
January 2024 BlueAlert
December 2023 BlueAlert
November 2023 BlueAlert
October 2023 BlueAlert
September 2023 BlueAlert
August 2023 BlueAlert
July 2023 BlueAlert
June 2023 BlueAlert
May 2023 BlueAlert
April 2023 BlueAlert
March 2023 BlueAlert
February 2023 BlueAlert
January 2023 BlueAlert
Code Edits and Code Updates
Code Editing for Facility High Level Emergency Room Services (July 1, 2024)
Office and Outpatient Evaluation and Management Visit Complexity Add-on Payment Code G2211 (Effective Jan. 1, 2024)
Ophthalmology Policies (Effective June 15, 2022)
Quality Care Quarterly Newsletter
Spring 2025 Quality Care Newsletter
Winter 2024 Quality Care Newsletter
Fall 2024 Quality Care Newsletter
Summer 2024 Quality Care Newsletter
Spring 2024 Quality Care Newsletter
Winter 2023 Quality Care Newsletter
Fall 2023 Quality Care Newsletter
Summer 2023 Quality Care Newsletter
Spring 2023 Quality Care Newsletter

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BlueAlert Provider Newsletter
The latest newsletter and current year’s editions. Previous years are stored in our archive.
2026 BlueAlert Newsletter
June BlueAlert
May BlueAlert
April BlueAlert
March BlueAlert
February BlueAlert
January BlueAlert

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Code Edits/Code Updates
These documents contain information about upcoming code edits.
Upcoming Code Edits (Effective Oct. 26, 2025)

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Upcoming Prior Authorization Changes
Here are the upcoming changes to prior authorization requirements.
High Tech Imaging Code Changes Effective August 17, 2026
Genetic Testing Code List Update Effective Aug. 2, 2026
High Tech Imaging Code Changes Effective Aug. 2, 2026
Genetic Testing Code List Updates Effective July 19, 2026
Manipulation of the Knee Joint Under General Anesthesia Effective June 1, 2026
Coronary Computed Tomography Angiography Effective June 1, 2026
Breast Surgery for Augmentation or Reduction Code List Update Effective 05.24.2026
Changes to Prior Authorization Submission Requirements Effective 04.24.2026
Radiation Oncology Code List Update Effective 01.01.2026
MSK Code Update Effective March 1, 2026
New PA Process for all LOB Effective December 2025
Air Ambulance PA Process Effective December 2025
Genetic Testing Code List Updates Effective 11.01.25
Genetic Testing Code List Update Effective 09.30.2025
New Commercial PA Submission Process Effective
Gender Reassignment Code List Update Effective 08.03.2025
MSK PA Changes Effective 05.01.2025
BH Afterhours Notifications Effective 04.01.2025
Genetic Testing Code List Updates Effective 01.01.2025

Documents & Forms

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Administration Manuals

Authorizations & Appeals

Behavioral Health

Quality Care Initiatives

Authorizations & Appeals

Behavioral Health

Pharmacies & Prescriptions

Quality Care Initiatives

Authorizations & Appeals

Behavioral Health

Pharmacies & Prescriptions

Quality Care Initiatives

Announcements & Notices

Archive

BlueAlert Provider Newsletter

Code Edits/Code Updates

Upcoming Prior Authorization Changes

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Authorizations