Documents & Forms
For your convenience, we've put these commonly used documents together in one place. Start by choosing your patient's network listed below. You'll also find news and updates for all lines of business.
- Commercial
- Medicare Advantage
- Medicare with Medicaid (BlueCare PlusSM)
- Medicaid (BlueCare)
- TennCareSelect
- CoverKids
- BlueCare CHOICES
- SelectCommunity
- News & Updates
Commercial
These manuals are your source for important information about our policies and procedures.
Forms and information to help you request prior authorization or file an appeal.
- Bariatric Surgery Authorization Request Form
- Care Management Contact Information
- Cite Guideline Quick Reference Guide
- Commercial Hospice Service Request Form
- Commercial Long Term Acute Care Hospitalization Request Form
- Commercial Lab Sleep Study Form
- Commercial Lab Sleep Studies Program CPT List
- Commercial/FEP Transplant Request Form
- Durable Medical Equipment (DME) Authorization Request
- Complex Rehab Tech (CRT) DME Authorization Request
- Federal Employee Gender Affirming Surgery Prior Approval Request Form
- Federal Employee Predetermination / Prior Approval Form
- Gender Reassignment Surgery Pre-certification Request Form
- High Tech Imaging Authorization CPT Codes
-
High Tech Imaging Authorization Request (Vendor eviCore)
- Home Health Services Request
- Medical Policy Appeals Process
- Musculoskeletal Epidural Steroid Injection Request (Vendor: Turning Point)
- Musculoskeletal Facet Joint Injection Request (Vendor: Turning Point)
- Musculoskeletal Joint and Spine Authorization Request (Vendor: Turning Point)
- Musculoskeletal Neurotomy Request (Vendor: Turning Point)
- Musculoskeletal Procedure/Pain Management Codes
- Predetermination Request
- Prior Authorization List
- Provider Reconsideration Helpful Guide
- Provider Dispute Resolution Procedure
- Radiation Oncology Therapy CPT Codes
- Reconsideration Process Map
- Services Authorization Fax Form
- Skilled Nursing Facility Rehab Form
- Speciality Pharmacy / Advanced Therapeutics Authorizations
- Utilization Management Appeal Form
- Vein Authorizations Form
Forms and information about behavioral health services for your patients
- Applied Behavior Analysis (ABA) Assessment, Initiation and Continuation Request Form
- Buprenorphine Medication Assisted Treatment (BMAT) Program Description
- Clinical Discharge Form
- FEP Applied Behavioral Analysis FAQs
- ICD-10 Information Update (July 2015)
- Psychiatric Clinical Service Authorization Request Form
- Psychological Testing Authorization Request Form
- Substance Abuse Clinical Service Authorization Request Form
- Transcranial Magnetic Stimulation (TMS) Pre-Authorization Request Form
Forms and information about pharmacy services and prescriptions for your patients.
- 2022 Affordable Care Act (ACA) $0 Copay Preventive List
- 2023 BlueCross Preventive Medication List
- Controlled Substance Prescribing
- 2023 Essential Medication List (Formulary)
- 2023 Essential Plus Medication List (Formulary)
- 2023 Preferred Medication List (Formulary)
- Prescription Mail Service Order Form
- Immunizing Pharmacist Vaccine Code List
- Medication Review Request Fax Cover
- Opioid Criteria
- OTC Savings Program
- Prescription Exception Request Form
- Provider Administered Specialty Medication List
- Medical Exclusions Medication List
- Provider Advanced Specialty Benefit Management Exception Request Form
- Specialty Pharmacy Network List
Information to help you maximize your performance in our quality programs.
- ADD/ADHD Medication Brochure (QPI-34)
- Commercial Advanced Illness and Frailty Guide
- Commercial Measures Guide
- Common Conditions and Antibiotic Resistance
- Episodes of Care Quick Reference Guide
- Episode of Care Risk Adjustment Methodology
- Episode of Care Risk Adjustment Factors and Weights
- Gainsharing Limits for Episodes of Care
- Guide to Reading Your Episode of Care Report
- Initiation and Engagement of Substance Abuse Treatment
- Low Back Pain Coding Tool
- Low Back Pain Provider Toolkit
- Provider Resource Guide
- Quality Care Measures
- Smoking and Tobacco Cessation with Medication
- THCII State Employee Health Plan and Fully Insured Program Guide
- THCII State Employee Health Plan and Fully Insured - FAQs
- 2020 Thresholds (SEHP)
- 2020 Thresholds (Fully Insured)
- 2019 Thresholds (SEHP)
- 2019 Thresholds (Fully Insured)
- 2018 Thresholds (SEHP)
- 2018 Thresholds (Fully Insured)
- 2017 Thresholds (SEHP)
- WCC and IMA Measures
Medicare Advantage
Forms and information to help you request prior authorization or file an appeal.
- Administered Part-B Specialty Drug List
- Care Management Contact Information
- Cite Guideline Quick Reference Guide
- Claim Status Check Form
- CMS Inpatient Only List
- Detailed Notice of Discharge
- Durable Medical Equipment (DME) Authorization Request Form
- High Tech Imaging Codes Requiring Authorization
- High Tech Imaging C Code Crosswalk Reference Guide
- Home Health Outpatient Therapies Service Request Form
- Inpatient/Outpatient Service Request Form
- Medicare Home Health Face-to-Face Encounter
- Medical Policy Appeals Process
- MSK Procedure/Pain Management Codes
- MSK Injections Form
- MSK Injections Authorization Request
- Notice of Medicare Non Coverage
- Physical Therapy/Occupational Therapy/Speech Therapy/Chiropractic Code List
- Potential Cosmetic Investigational or Non Covered Procedure Code List
- PPO FAQs
- PPO fax cover sheet
- Predetermination Authorization Request Form
- Provider Reference Guide / Prior Authorization List
- Provider Reconsideration Form
- Provider Appeals Form
- Provider Appeals Form (Post-Services for Utilization Management)
- Provider Dispute Resolution Procedure
- Radiation Code List
- Reconsideration and Appeals Guide
- Reconsideration Process Map
- Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
- Waiver of Liability Statement
2022 Summary of Benefits
- BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald
- BlueAdvantage Summary of Benefits Middle and West - Garnet
- BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald
- BlueAdvantage Summary of Benefits Northeast - Sapphire
- BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald
- BlueAdvantage Summary of Benefits Southeast - Sapphire
- BlueAdvantage Summary of Benefits Freedom
Forms and information about behavioral health services for your patients.
Forms and information about pharmacy services and prescriptions for your patients.
- Controlled Substance Prescribing
- Prescription Mail Service Order Form
- Immunizing Pharmacist Vaccine Code List
- 2022 Medicare Advantage (BlueAdvantage) Medication List (Formulary)
- 2023 Medicare Advantage (BlueAdvantage) Medication List (Formulary)
- Part B Step Therapy Provider Reference Guide
- Provider Administered Specialty Medication List
- 2022 Prior Authorization Criteria
- 2023 Prior Authorization Criteria
Information to help you maximize your performance in our quality programs.
- 4 STAR and Above Providers
- Cognitive Assessment Tool
- Diabetes Prevention Program
- Dementia Risk Adjustment Documentation
- Depression Screening Tool
- Differences Between Statin Star Measures
- Fall Risk Assessment Tool
- Guide to Advanced Illness and Frailty Exclusions
- PCP Change Form
- Physician Now FAQs
- Quality+ Partnerships Program Guide
- Quality+ Partnership Program Measures
- Risk Adjustment Program
Medicare with Medicaid (BlueCare PlusSM)
Forms and information to help you request prior authorization or file an appeal.
- Appeals Process Map
- BlueCare Plus Provider Attestation Form
- Care Management Contact Information
- Certificate of Medical Necessity for Abortion Form
- Cite Guideline Quick Reference Guide
- Cite Guideline Transparency
- Commercial MSK Procedure/Pain Management Codes
- Consent for Sterilization Form
- High Tech Imaging C Code Crosswalk Reference Guide
- Home Health Missed Visit Form
- Initial Member/Caregiver Training Checklist
- Instructions for completing Certificate of Medical Necessity for Abortion
- Instructions for completing Consent for Sterilization Form
- Medical Policy Appeals Process
- Medicare Advantage Provider- Administered Part-B Specialty Drug List
- Potential Cosmetic Investigational or Non Covered Procedure Code List
- Private Duty Nursing/Home Health Plan of Care
- Private Duty Nursing Home Plan of Care Agreement
- Provider Appeals Form
- Provider Dispute Resolution Procedure
- Provider Helpful Guide
- Provider Reconsideration Form
- Recertification Member/Caregiver Training Checklist
- Reconsideration Process Map
- Skilled Nursing Facility Rehab Form
- Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
- Waiver of Liability Statement
Forms and information about pharmacy services and prescriptions for your patients.
- Controlled Substance Prescribing
- 2021 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- 2022 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- 2023 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- 2021 Prior Authorization Criteria
- 2022 Prior Authorization Criteria
- 2023 Prior Authorization Criteria
Information to help you maximize your performance in our quality programs.
Enrollment
These documents contain information about your benefits, network and coverage.
- Behavioral Health Professional Services Information
- CAQH Proview News
- CAQH ProView Practice Manager Quick Reference Guide
- CAQH ProView Practice Manager User Guide
- CAQH ProView Provider Quick Reference Guide
- CAQH ProView Provider User Guide
- CHOICES Enrollment Form
- Facility Admitting Practitioner Form
- Medical Management Corrective Action Program
- Pain Management Form for Nurse Practitioner or Physician Assistant
- Professional Provider Associated Professional Listing
- Supervising Physician Form for Nurse Practitioner or Physician Assistant
Technical Support
These documents contain information about your benefits, network and coverage.
- 270 Companion Guide
- 276 Companion Guide
- 835 Companion Guide
- Dental Edits
- eBusiness Marketing Team Regional Map
- eBusiness User Guide
- EDI Corrected Claims Guidelines
- Electronic Claims Frequently Asked Questions (FAQs)
- Electronic Provider Profile Form
- Electronic Secondary Claim Guidelines
- Electronic Vendor Profile Form
- Institutional Edits
- Professional Edits
- PWK Coversheet
- NPI Line Level Adjudication Changes
- Secure File Gateway Instructions (HTTPS)
- Secure File Gateway (SFG) Request For Access Form
- Supplemental BlueCare/TennCareSelect Edits
- Supplemental EDI Information