We require this form for credentialing and recredentialing. By signing it, you attest to the accuracy of the information in your credentialing application and consent to the release of information we need to evaluate your request. The form must be dated within 180 days of your request.
This file combines the Blue Cross cover sheet with the Mass Collaborative form.
Behavior Analysts, please use the form for Ancillary Professionals.
For Dental Blue 65 members, use the Dental Blue 65 Enhanced Dental Benefit Enrollment Form.
For Dental Blue 65 members, use the Dental Blue 65 Enhanced Dental Benefit Enrollment Form.
Use this form ONLY for habilitative serviceshabilitative services. Habilitation services are defined as health care services that help a person keep, learn, or improve skills and functioning for daily living.
Fax this form to our Medicare Pharmacy Operations team at 1-866-463-7700 when a hospice patient has been or may be denied a medication at the pharmacy, or to communicate a beneficiary’s change in hospice status.
Out-of-network providers can review the No Surprises Act (NSA) language related to initiating a federal Independent Dispute Resolution (IDR) request. An IDR request may be submitted following the unsuccessful conclusion of an Open Negotiation period in order to determine the out-of-network rate for certain qualified items or services.
Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.
Please do not use this form for members in long-term care requiring physical, occupational, or speech therapy. For authorization instructions, visit Outpatient Rehabilitation Therapy.
Use this application if you would like to bill for the technical component of X-rays, ophthalmic A scans, and limited/follow-up obstetrical ultrasounds.
For Medicare prior authorization or formulary exception requests
Use this form to grant Blue Cross and Blue Shield of Massachusetts permission to make a single disclosure of specific information to a specific person when that disclosure is not otherwise allowed by law.
This file combines the Blue Cross cover sheet with the Mass Collaborative form.
This file combines the Blue Cross cover sheet with the Mass Collaborative form.
The Request for Claim Review form is the final page in the guide. The guide and form were created by the MassCollaborative.
Institutional providers may use this form to notify us of a change in ownership or control.
Please file this form one week prior to the last covered service. For more instructions on how to complete the form, refer to our Guide.
This is a Mass Collaborative form. Note: for contractual changes, please use the appropriate Contract Update form. For more information, go to Maintaining & Changing StatusMaintaining & Changing Status.
Use this application if you would like to bill for the technical component of any diagnostic imaging modality.
Institutional providers use this form to notify us of contractual or non-contractual changes. To add an individual clinician to your contract, please use a form for professional providers.
Institutional providers use this form to notify us of contractual or non-contractual changes. To add an individual clinician to your contract, please use a form for professional providers.
