Institutional Provider Forms
Body
- Refund/Deduct Authorization (offsite link)
- Room Rate Registration Form (offsite link)
- Claim/Enrollment Inquiry
- Electronic Fund Transfer (EFT) Form (offsite link)
- Other Party Liability
- Claim Appeal Representative Authorization Form * (Form 29-58)
- Limited Patient Waiver* (Form 15-169)
- OPL Deduct Authorization Form* (Form 29-203)
- Other Party Liability Questionnaire (Form 34-704)
- Predetermination Request Form * (Form 15-17)
- Prime Coverage Exception (offsite link)
- Refund/Deduct Authorization* (Form 29-202)
Provider BlueCard Claim Appeal Form
This appeals form, which is standard and supported by each Blue Cross and Blue Shield Company, can be used to initiate provider appeals for BlueCard claims.
BlueCard Claim Appeal Form (MS Word .docx)
If your patient's plan is subject to their State’s mandated provider appeal process, please check the patient’s Home Plan website for more information on regulated appeal filing procedures, timeframes, and utilize the appeal forms/applications if mandated by the State that regulates the patient’s plan.
Blue Cross and Blue Shield of Kansas will also continue to support Claim Appeal Representative Authorization Form (PDF) (Form 29-58). To help with timeliness and to avoid confusion, please do not initiate both forms to appeal the same claim.