Professional Provider Forms

The following forms can be completed and submitted online.

• Refund/Deduct Authorization (offsite link)
• Claim/Enrollment Inquiry
• Electronic Fund Transfer (EFT) Form (offsite link)
• Other Party Liability
• CAQH Provider ID Request (offsite link)

 The following documents are in PDF format.

• Behavioral Health Provider Areas of Expertise *
• Case Management Referral Form *
  (Form 15-261C)
• Certificates of Medical Necessity
  • For supplies/medical equipment without specific CMN*
    (Form 15-405)
  • Oxygen – This CMN is not required with the claim. It is completed by the ordering physician and maintained in file by the oxygen provider.*
    (Form 15-406)
  • Seat lift chair/patient lift and sit to stand/standing frame systems*
    (Form 15-503)
  • Hospital Bed*
    (Form 15-506)
  • Lymphedema Compressor*
    (Form 15-508)
  • Manual Wheelchair*
    (Form 15-509)
  • Motorized Wheelchair*
    (Form 15-510)
  • Power Operated Vehicle*
    (Form 15-513)
  • Pulse Oximeter*
    (Form 15-514)
  • Support Surfaces (Mattresses and Pads) *
    (Form 15-515)
• Claim Appeal Representative Authorization Form *
  (Form 29-58)
• Disease Management and Wellness Program Referral Form *
  (Form 7-538)
• Limited Patient Waiver *
  (Form 15-169)
• Medical Necessity Form for Periodontal Therapy with a Controlled Chemotherapy Agent *
  (Form 15-721)
• New Directions Psych Testing Form
  (Form 42-4)
• OPL Deduct Authorization Form*
  (Form 29-203)
• Other Party Liability Questionnaire*
  (Form 34-704)
• Predetermination Request Form *
  (Form 15-17)

• Prior Authorization (PA) Forms

   

  • ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial *
  • BRCA1 and BRCA2 Testing *
  • Compounded Prescriptions *
  • Human Growth Hormone *
  • Prior Authorization Request Form *
  • Site of Care Infusion Management *
• Prime Coverage Exception (offsite link)
• Prime Coverage Exception fax form (offsite link)
• Provider Change of Information Form
  (Form 15-141)
• Refund/Deduct Authorization*
  (Form 29-202)
• Request to Receive Service Outside of Solutions Network *
  (Form 15-504)
• Provider Network Application*
  (Form 15-481)
• Alteration/Forgery/Unauthorized Signature Affidavit*

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.

* You may fill out and print this form using your acrobat reader program.