Documents & Forms
For your convenience, we've put the 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
- Medicaid with Medicare (BlueCare PlusSM)
- Medicaid (BlueCare)
- TennCareSelect
- CoverKids
- BlueCare CHOICES
- SelectCommunity
- News & Updates
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Commercial
Commercial
Administration Manuals
These manuals are your source for important information about our policies and procedures.
Authorizations & Appeals
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
- Durable Medical Equipment (DME) Authorization Request
- Gender Reassignment Surgery Pre-certification Request Form
- High Tech Imaging Authorization CPT Codes
- High Tech Imaging Authorization Request (Vendor: CareCore National)
- Home Health Services Request
- Medical Policy Appeals Process
- Musculoskeletal Authorization Request (Vendor: Turning Point)
- Musculoskeletal Epidural Steroid Injection Request (Vendor: Turning Point)
- Musculoskeletal Facet Joint Injection Request (Vendor: Turning Point)
- Musculoskeletal Neurotomy Request (Vendor: Turning Point)
- Musculoskeletal Procedure/Pain Management Codes
- Musculoskeletal Surgical Intake Request (Vendor: Turning Point)
- 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
- Utilization Management Appeal Form
Behavioral Health
Forms and information about behavioral health services for your patients
- Applied Behavior Analysis (ABA) Assessment, Initiation and Continuation Request Form
- 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
Coverage & Claims
- Acknowledgement of Financial Responsibility Form
- Acknowledgement of Financial Responsibility for the Cost of Equipment Upgrades and Supplies
- Chiropractic Payment Trigger Code List
- Coordination of Benefits Questionnaire (COB)
- Medical Claim Form
- Preventative Diabetic ICD-10 Diagnosis Codes
- Remittance Advice Explanation Codes with CARC and RARC List
Pharmacies & Prescriptions
Forms and information about pharmacy services and prescriptions for your patients.
- 2020 Affordable Care Act (ACA) $0 Copay Preventive List
- Controlled Substance Prescribing
- 2020 Essential Medication List (Formulary)
- 2020 Essential Plus Medication List (Formulary)
- Express Scripts Pharmacy Mail 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
- Specialty Pharmacy Network List
- Immunizing Pharmacist Vaccine Code List
Quality Care Initiatives
Information to help you maximize your performance in our quality programs.
- ADD/ADHD Medication Brochure (QPI-34)
- BlueCross Performance Rating
- 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
- 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
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Medicare Advantage
Medicare Advantage
Authorizations & Appeals
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
- 2020 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
- PPO FAQs
- PPO fax cover sheet
- Predetermination Authorization Request Form
- 2020 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
Coverage & Claims
- BlueEssential Summary of Benefits
- Summary of Benefits Middle and West - Diamond, Ruby, Emerald
- Summary of Benefits Middle and West - Garnet
- Summary of Benefits Northeast - Diamond, Ruby, Emerald
- Summary of Benefits Northeast - Sapphire
- Summary of Benefits Southeast - Diamond, Ruby, Emerald
- Summary of Benefits Southeast - Sapphire
Behavioral Health
Forms and information about behavioral health services for your patients.
Pharmacies & Prescriptions
Forms and information about pharmacy services and prescriptions for your patients.
- Controlled Substance Prescribing
- Express Scripts Pharmacy Mail Order Form
- High-Risk Medication Therapeutic Alternatives Guide
- Immunizing Pharmacist Vaccine Code List
- 2020 Medication List (Formulary)
- Part B Step Therapy Provider Reference Guide
- Part D Coverage Determination ePA
- Provider Administered Specialty Medication List
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
- 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
- Provider Assessment Form
- Quality+ Partnerships Program Guide
- Quality+ Partnership Program Measures
- Risk Adjustment Program
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Medicaid with Medicare (BlueCare PlusSM)
Medicaid with Medicare (BlueCare PlusSM)
Authorizations & Appeals
Forms and information to help you request prior authorization or file an appeal.
- Appeals Process Map
- 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
- Musculoskeletal Authorization Request Form (Intake Form)
- 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
- Surgical Intake Form
Pharmacies & Prescriptions
Forms and information about pharmacy services and prescriptions for your patients.
Quality Care Initiatives
Information to help you maximize your performance in our quality programs.
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Enrollment
Enrollment
Contracting and Credentialing
These documents contain information about your benefits, network and coverage.
- Provider Change Form
- Out Of Network Provider Form
- CHOICES Enrollment Form
- Supervising Physician Form for Nurse Practitioner or Physician Assistant
- Facility Admitting Practitioner Form
- Professional Provider Associated Professional Listing
- Behavioral Health Professional Services Information
- Pain Management Form for Nurse Practitioner or Physician Assistant
- Medical Management Corrective Action Program
- CAQH Proview News
- CAQH ProView Provider User Guide
- CAQH ProView Provider Quick Reference Guide
- CAQH ProView Practice Manager User Guide
- CAQH ProView Practice Manager Quick Reference Guide
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Technical Support
Technical Support
Technical Support/ eBusiness Information
These documents contain information about your benefits, network and coverage.
- Electronic Provider Profile Form
- Electronic Vendor Profile Form
- Secure File Gateway (SFG) Request For Access Form
- Secure File Gateway Instructions (HTTPS)
- Institutional Edits
- Professional Edits
- Dental Edits
- Supplemental BlueCare/TennCareSelect Edits
- eBusiness User Guide
- 270 Companion Guide
- 276 Companion Guide
- 835 Companion Guide
- NPI Line Level Adjudication Changes
- Electronic Secondary Claim Guidelines
- EDI Corrected Claims Guidelines
- PWK Coversheet
- Supplemental EDI Information
- Electronic Claims Frequently Asked Questions (FAQs)
- eBusiness Marketing Team Regional Map
- EFT Brochure