Forms

• Behavioral Health Provider Practice Information Survey

  By taking part in this survey, you’re helping ensure that our members have the most up-to-date information about your practice.

• Case Management Referral Form

  Please complete this form to refer a member for case management services.

• Patient Coordination of Benefit
  To process claims timely and accurately, it’s important that we know if a patient has any health insurance coverage other than Blue Cross & Blue Shield of Rhode Island. If your patient has other coverage, please complete this form. You can fax it to (401) 459-1137 or mail it to:

   

  Attn: Provider COB – 00043

  Blue Cross & Blue Shield of Rhode Island

BlueCHiP Checklists

• BlueCHiP for Healthy Options PCP Checklist (Adolescent)

  BlueCHiP for Healthy Options members: To maintain Advantage-level benefits, this form must be completed by the primary care physician (PCP) of each family member on your plan aged 12 to 17.

• BlueCHiP for Healthy Options PCP Checklist (Adult)

  BlueCHiP for Healthy Options members: To maintain Advantage-level benefits, this form must be completed by the primary care physician (PCP) of each family member on your plan aged 18 or older.

Claims & Billing

• Claims Adjustment Request
• CMS-1500 (02-12) Form Completion Informational Guide

  This guide is designed to help you when completing the CMS-1500 (02-12) form.

• CMS-1500 (08-05) Form Completion Informational Guide

  This guide is designed to help you when completing the CMS-1500 (08-05) form.

• Coordination of Benefits Questionnaire
• Dental Claim Adjustment Form
• Direct Deposit Agreement
• Modifier 22 - Unusual Procedural Services
• Offshore Subcontracting Questionnaire
• Provider Appeal Request Form
• Unlisted Code Claim Form for Durable Medical Equipment and Orthotics & Prosthetics Providers
• Unlisted Procedure Claim Form for Facilities
• Unlisted Procedure Claim Form for Physicians
• W-9

  Form for providing taxpayer identification number and certification for federal reporting purposes.

Coordination of Patient Care

• Behavioral Health Extension of Outpatient Benefits Form
• Care Coordination Referral Form
• Infertility Treatment Form
• Instructions for Completing the Oral Enteral Food Products Reimbursement Form
• Medical Records Cover Sheet
• Oral Enteral Food Products Reimbursement Form
• Physical Therapy and Occupational Therapy Preauthorization Form
• Preauthorization Form for Oral Enteral Nutrition
• Referral Form
• SNF Pharmacy Cover Sheet
• SNF Pharmacy Reimbursement Form

Provider Access / Administrative

• Email Address Update Form
• Policy Request Form
• Practitioner Change Form

  Please use this form to notify us of any changes to your practice.

• Primary Care Physician Selection Form
• Primary Care/Behavioral Health Communication Form

  This form is designed to increase communication and provide care coordination between behavioral health and primary care providers.

• Voluntary Termination