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Administrative
Update Form for Facilities

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 (above).


Clinical Criteria Request Form


Electronic Remittance Advice Enrollment Form (Submit Online)
Enhanced Dental Benefit Enrollment Form

For Dental Blue 65 members, use the Dental Blue 65 Enhanced Dental Benefit Enrollment Form.


Notice of Medicare Non-Coverage for Home Health Care
Notice of Medicare Non-Coverage for Skilled Nursing Facilities
Referral for Health Management Programs & Services
Paper Remittance Copy Request
Continuity/Transition of Care Request
Hospice Information for Medicare Part D Plans

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.


Permission for One-Time Disclosure of Information

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.


Standardized Provider Information Change Form

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.


Dental Blue 65 Enhanced Dental Benefit Enrollment Form
Authorization
Continuity/Transition of Care Request
Behavioral Health - Level of Care Request Supplemental Form

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.


Continuation of Care Request for Providers Disengaging from our Networks
Automatic Fax-Back Program: Request Form

Universal Home Health Authorization Form
Initial Precertification Form for SNF/Rehab/LTCH

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.


Psychological and Neuropsychological Assessment Supplemental Form

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.


Pre-Authorization for Non-Emergent Ground Ambulance Transport
Pre-Certification / Pre-Authorization Request
Repetitive Transcranial Magnetic Stimulation Supplemental Form

Use this supplemental form as a cover sheet for the standardized Mass Collaborative form.


Short-Term Rehabilitation Therapy Extension Request Form
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.

Short-Term Rehabilitation Speech Therapy Extension Request Form
Skilled Nursing Facility Level of Care Form for Medex Members
Prior Authorization Request for Medically Necessary Orthodontia Services for Pediatric Essential Health Benefits
Handicapping Labio-Lingual Deviations (HLD Index 4)
Assisted Reproductive Technology (ART) Services Form
Habilitative Therapy Request Form for HMO Members

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.


Managed Care Out-of-Network Request Form
SNF/Rehab/LTCH Clinical Recertification Request Form
Esketamine Nasal Spray and Intravenous Ketamine for Treatment Resistant Depression: Prior Authorization Request Form
Applied Behavior Analysis Service Request Form
Authorization - Pharmacy
Massachusetts Standard Form for Medication Prior Authorization Requests
Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests
Massachusetts Standard Form for Synagis® Prior Authorization Requests
Medicare Part D Coverage Determination Request Form

For Medicare prior authorization or formulary exception requests


Home Infusion Therapy Prior Authorization Request Form
Contracting Applications
Contracting Application for Audiologists, Chiropractors, Optometrists, and Licensed Dietitian Nutritionists
Behavioral Health Clinical Profile
Certified Nurse-Midwife (CNM) Contracting Application
Certified Registered Nurse Anesthetist (CRNA) Contracting Application
Clinical Roster for Provider Application
MD Group Contracting Application
NP Contracting Application
PA-PCP and NP-PCP Contracting Application
Physical Therapist, Occupational Therapist, and Speech Language Pathologist Contracting Application
Podiatrist Contracting Application
Psychiatric Nurse Practitioner and Clinical Nurse Specialist Contracting Application
Psychiatrist, Psychologist, Licensed Alcohol and Drug Counselor (LADC-I), LICSW, LMFT, and LMHC Contracting Application
Provider Application (for Ancillary Institutional Providers)
Licensed Applied Behavioral Analyst
Opioid Treatment Program Application
Dental Network Application
Acupuncturist Contracting Application
PA Contracting Application
Birth Center Contracting Application
Contract Updates
Contract Update Form for Physician Assistants and Ancillary Advanced Practice Nurses
Update Form for Facilities

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 (above).


Contract Update Form for Ancillary Professional Providers

Behavior Analysts, please use the form for Ancillary Professionals.


Contract Update Form for Behavioral Health Professionals
Contract Update Form for NP-PCPs and PA-PCPs
Contract Update Form for Physicians
Request for Consent to Assignment of Provider Contracts

Institutional providers may use this form to notify us of a change in ownership or control.


Credentialing and Recredentialing
Applicant’s Authorization and Release of Information

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.


Recredentialing Application for Dentists and Oral Surgeons
HCAS Enrollment Form (hcasma.org)
Dental Claims & Requests
ADA Claim Form
Privileging
Diagnostic Imaging Professional Privileging Application
Endovenous Ablation Professional Privileging Application
Nuclear Cardiology Consensus Criteria Application
Limited Technical Privileging Application

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.


TDI Privileging Application

Use this application if you would like to bill for the technical component of any diagnostic imaging modality.


Privileging Exception Request Form
Review & Appeals
Coordination of Benefit Questionnaire
Non-Covered Service Waiver
Request for Claim Review Form and Reference Guide (masscollaborative.org)

The Request for Claim Review form is the final page in the guide. The guide and form were created by the MassCollaborative.


Open Negotiation Notice

Out-of-network providers can use this form to initiate the independent dispute resolution process allowed under the No Surprises Act.