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Formularios

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Salud mental

Formulario	Descripción
• Formulario de solicitud de servicios clínicos de Análisis Conductual Aplicado (ABA) • Applied Behavior Analysis (ABA) Initial Assessment Request
Coordination of Care Form	Use to provide member treatment information to or from another treating provider
Electroconvulsive Therapy Request	Request for review of medical necessity
Intensive Outpatient Program Request	Request for review of medical necessity
Professional Areas of Expertise Form	This form is required for all behavioral health professionals.
Facility Areas of Expertise Form	This form is required for all behavioral health facilities.
Solicitud de pruebas psicológicas/neuropsicológicas	Request for review of medical necessity
Repetitive Transcranial Magnetic Stimulation (rTMS) Form	Request for prior authorization
Supervision via Telehealth Request & Attestation	Request for telehealth services for ABA
Transitional Care Request – Behavioral Health	This form must be completed by the member and/or provider for any Blue Cross and Blue Shield of New Mexico (BCBSNM) member receiving ongoing behavioral health care with an out-of-network provider.
NM Uniform Prior Authorization Form	Use for services requiring prior authorization

Blue Cross Medicare Advantage-specific forms

Formulario	Descripción
Medicare – Electroconvulsive Therapy Request	Request for review of medical necessity
Medicare – Psychological/Neuropsychological Testing Request	Request for review of medical necessity
Medicare – Repetitive Transcranial Magnetic Stimulation (rTMS) Form	Request for prior authorization

Blue Cross Community Centennial℠ Specific Forms

Formulario

Descripción

Salud mental

This form is required to be submitted for ABA Stage 3 planning and treatment
This form is required to be submitted for ABA Specialty Care Provider Prior Authorization
This form is required to be submitted with a request of clinical information for any review
Request for review of medical necessity
Request for review of medical necessity
Request for preauthorization

Reclamaciones

This guide will help providers complete the CMS-1500 form
Request for an appeal on behalf of a Blue Cross Community Centennial member
Use this form to self-report overpayments identified by the provider

Gestión Médica

Providers who disagree with a NFLOC determination can request reconsideration
Form and instructions to notify the County Income Support Division office of the birth of a child to a New Mexico Medicaid eligible mother
Use when a Medicaid member is changing level of care
Request authorizations for Blue Cross Community Centennial (Medicaid) members, including for drugs requiring preauthorization under the Blue Cross Community Centennial plan.

Reclamaciones

Formulario	Descripción
Check and Voucher Request Form	Effective July 11, 2016, duplicate copies of PCS vouchers may no longer be requested using this form.
Claim Review Form	Use this form to request a review of a previously adjudicated claim.
Additional Information Claim Form	Use this form to submit requested additional information.
Corrected Claim Form	Use this form to request corrections to a previously adjudicated claim when you are unable to submit the corrections electronically.
Credentialing and Reimbursement Dispute Form	This form is only to be used for review of a delay in claim reimbursement when provider credentialing is simultaneously delayed.
Coordinación de beneficios	To be completed by the member if enrolled with another carrier
Medicare Reconsideration Form	Use this form to submit a request for an adjustment for a claim that was excluded from crossing over to BCBSNM due to the Medicare mass adjustment process, as related to 2010 Medicare physician fee schedule changes and certain provisions of the affordable care act.
Provider Refund Form	Use this form when a refund is due to BCBSNM and you would like to send in a voluntary check for the refund.
Provider Request for Appeal on Behalf of a Member	Request for an appeal on behalf of a member — for commercial members
UB-04 User Guide	This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage.

Comercio electrónico

Formulario Descripción
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Formulario	Descripción
Availity.com	Enroll online for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) via Availity^® – learn more!

Gestión Médica

Formulario	Descripción
Medicare Annual Wellness Visit Form	This form and its accompanying Medicare Advantage Annual Wellness Visit Guide may be helpful to follow during our Medicare members' wellness visits.
Catastrophic Petition Request	Use as a cover sheet when submitting catastrophic record documentatio
Pruebas genéticas	Request for Tier 2 genetic tests
Hyperbaric Oxygen (HBO) Pressurization Form	Request for HBO pressurization treatment
MAD 062 Personal Care Transfer-Closure Form	Request for Personal Care Service transfer/closure.
NM Uniform Prior Authorization Form	Use for services requiring prior authorization.
Solicitud de predeterminación	Use for services requiring predetermination
Proton Beam Radiation Therapy Physician Worksheet	Request benefit predetermination for proton beam radiation therapy
Transitional Care Request	Request for BCBSNM members requiring ongoing care for an existing medical condition.
Wheelchair Medical Necessity and Home Evaluation Verification	Request for manual and power wheelchairs, scooters and other power-operated vehicles

Member/Patient

Formulario	Descripción
Standard Authorization Form and other HIPAA Privacy Forms for Medicaid Members	Blue Cross Community Centennial members can use these forms to provide authorization for BCBSNM to share Protected Health Information (PHI) or make other requests related to their privacy.
Formulario de Autorización Estándar y otros Formularios de Privacidad de la HIPAA	All other BCBSNM plan members can use these forms to provide authorization for BCBSNM to share Protected Health Information (PHI) or make other requests related to their privacy.

Red

Formulario	Descripción
Applications to join the BCBSNM network	Complete the appropriate form(s) as described.
Fee Schedule Request	Request a copy of the CPT fee schedule.
Provider Disclosure Form	Complete before entering into or renewing a Medicaid provider contract, within 35 days after any change in ownership of the disclosing provider, or upon request as applicable.
Request to Establish or Revise a Non-Contracted Facility Record	Request to establish a new record or revise an existing record for a non-contracted facility provider
Request to Establish or Revise a Non-Contracted Provider Record	Request to establish a new record or revise an existing record for a non-contracted professional provider
W-9 Form	Request for taxpayer identification number and certification

Farmacia

Formulario	Descripción
Express Scripts^® Pharmacy Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or call 888-327-9791 for faxing instructions	Fax forms must be sent from a physician's office
Accredo Specialty Pharmacy General Use Fax Form	Specialty pharmacy drugs fax form for general use
Accredo Specialty Pharmacy Referral Forms by Therapy	Specialty pharmacy drugs fax form by drug therapy
NM Uniform Prior Authorization Form	Use for drugs requiring preauthorization under BCBSNM commercial plans fax to 877-243-6930

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