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
- 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.
- Provider Dispute Resolution Procedure
- Provider Reconsideration Form
-
Provider Appeal Form (Claim Reconsideration
Appeal)
- Utilization Management Appeal Form
- Air Ambulance Fax Form
- 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 Program and Postal Prior Approval List
- Federal Employee and Postal Gender Affirming Surgery Prior Approval Request Form
- Federal Employee and Postal Predetermination / Prior Approval Form
- Federal Employee and Postal Hearing Aid Prior Approval Request Form
- Federal and Postal Employee Program Provider-Administered Medication Authorization Form
- Gender Reassignment Surgery Pre-certification Request Form
- Genetic Testing Authorization Request (Effective 9/1/24)
- High Tech Imaging Authorization Codes
- High Tech Imaging Authorization Request Form
- High Tech Imaging Frequently Asked Questions
- Home Health Services Request
- Inpatient/Outpatient Services Prior Authorization Request Form
- 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
- Prior Authorization Start & Term Dates
- Provider-Administered Medication Authorization
- Provider Attestation for Abortion Services
- Provider Attestation Form for Gender-Affirming Services
- Radiation Oncology Authorization Request (Effective 9/1/24)
- Radiation Oncology Therapy CPT Codes
- Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
Appeals
Authorizations
Forms and information about behavioral health services for your patients
- Applied Behavioral Analysis (ABA) Therapy Services Request Form
- Applied Behavioral Analysis (ABA) 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.
- 2025 Essential Medication List (Formulary)
- 2025 Essential Plus Medication List (Formulary)
- 2025 Preferred Medication List (Formulary)
- 2025 BlueCross Preferred Preventive Drug List
- 2025 Choice Medication List (Formulary)
- 2025 Control Medication List (Formulary)
- 2025 Control and Choice Preventive Drug List
- 2025 What's Changing Document: Preferred Medication List (Formulary)
- Affordable Care Act (ACA) $0 Copay Preventive List
- Controlled Substance Prescribing
- Stimulant Prescribing Guidelines
- Immunizing Pharmacist Vaccine Code List
- Medical Exclusions Medication List
- Medication Review Request Fax Cover
- Opioid Criteria
- OTC Savings Program
- Prescription Exception Request Form
- Prescription Mail Service Order Form
- Prior Authorization Criteria
- Upcoming Prior Authorization Changes
- Provider Administered Specialty Medication List (Updated: 4/1/2025)
- Provider-Administered Medication Authorization
- Provider Administered Specialty Medication Step Therapy Guide
- Provider Advanced Specialty Benefit Management Exception Request Form
- Specialty Pharmacy Network List
Information to help you maximize your performance in our quality programs.
- Antibiotic Stewardship Toolkit
- Episodes of Care Quick Reference Guide
- Episode of Care Risk Adjustment Methodology
- Guide to Reading Your Episode of Care Report
- Low Back Pain Coding Tool
- Low Back Pain Provider Toolkit
- Quality Care Measures & Comprehensive Program Information Guide
- THCII State Employee Health Plan and Fully Insured Program Guide
- THCII State Employee Health Plan and Fully Insured - FAQs
Medicare Advantage
Forms and information to help you request prior authorization or file an appeal.
- Provider Dispute Resolution Procedure
- Provider Reconsideration Form
- Provider Appeal Form (Claim Reconsideration
Appeal)
-
Utilization Management Appeal Form
- 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
- Hospital Services Review Process and FAQs
- Home Health Outpatient Therapies Service Request Form
- Inpatient/Outpatient Service Request Form
- Master Prior Authorization List
- Master Prior Authorization List Code Removals
- Medicare Home Health Face-to-Face Encounter
- Medical Policy Appeals Process
- MSK Injection Authorization Request Form
- Notice of Medicare Non Coverage
- PPO FAQs
- PPO fax cover sheet
- Predetermination Authorization Request Form
- Provider Reference Guide / Prior Authorization List
- Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
- Waiver of Liability Statement
Appeals
Authorizations
Forms and information about behavioral health services for your patients.
Forms and information about pharmacy services and prescriptions for your patients.
- 2025 Medicare Advantage (BlueAdvantage) Medication List (Formulary)
- 2025 Medicare Advantage (BlueAdvantage Extra) Medication List (Formulary)
- 2025 Medicare Part D Prior Authorization Criteria (Updated: 10/22/2024)
- Medicare Part B Prior Authorization Criteria
- Controlled Substance Prescribing
- Immunizing Pharmacist Vaccine Code List
- Part B Step Therapy Reference Guide (Updated: 12/1/2024)
- Part D - Prescription Hierarchical Condition Categories (RxHCC)
- Prescription Mail Service Order Form
- Provider Administered Specialty Medication List (Updated: 4/1/2025)
- Provider-Administered Medication Authorization Form
- Prescription Mail Service Order Form
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.
- Provider Dispute Resolution Procedure
- Provider Reconsideration Form
-
Provider Appeal Form (Claim Reconsideration Appeal)
- Advance Determination Decision
- Advance Determination Request
- Appeals Process Map
- BlueCare Plus Health Food Provider Attestation Form
- Care Management Contact Information
- Certificate of Medical Necessity for Abortion Form
- Cite Guideline Quick Reference Guide
- 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
- Initial Member/Caregiver Training Checklist
- 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
- Medicare Advantage Provider- Administered Part-B Specialty Drug List
- MSK Procedure/Pain Management Codes
- 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
- Recertification Member/Caregiver Training Checklist
- Skilled Nursing Facility Rehab Form
- Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
- Waiver of Liability Statement
Appeals
Authorizations
Forms and information about pharmacy services and prescriptions for your patients.
- 2025 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- 2025 Medicare Part D Prior Authorization Criteria (Updated: 10/22/2024)
- Medicare Part B Prior Authorization Criteria
- Provider-Administered Specialty Medication List (Updated: 4/1/2025)
- Provider-Administered Medication Authorization Form
- Controlled Substance Prescribing
- Part B Step Therapy Reference Guide (Updated: 12/1/2024)
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
- Provider Enrollment Updates and Changes Track a Request Guide
- 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
- Medicaid Reclamation New Carrier Form
- Medicaid Subrogation / Managed Care Organization / Medicaid Agencies Change Form
- NPI Line Level Adjudication Changes
- Professional Edits
- PWK Fax Cover Sheet
- Secure File Gateway Instructions (HTTPS)
- Secure File Gateway (SFG) Request For Access Form
- Supplemental BlueCare/TennCareSelect Edits
- Supplemental EDI Information