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Here are some of the most commonly used forms. If you are looking to update your address, add a site location, or notify us of other contractual changes, please log in and go to Office Resources> Enrollment>Maintaining & Changing Status

Administrative
Update Form for Facilities

Ancillary institutional providers use this form to notify us of contractual or non-contractual changes.


Clinical Criteria Request Form
Electronic Remittance Advice Enrollment Form (Submit Online)
Enhanced Dental Benefit Enrollment Form
Noninvasive Prenatal Testing for Fetal Aneuploidies Claim Attachment
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
Transition of Care Request for New Members (member form)
Hospice Information for Medicare Part D Plans

Fax us this form 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 Status.


Authorization
Applied Behavior Analysis Service Request Form
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
Daily Notification Report Request: Automatic Fax-back Program
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.


Methadone Authorization Request Form
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
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 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
Continuity of Care Request Form (most plans)

This form is completed by providers and members (who have an HMO, PPO, EPO, or Indemnity health plan) when a health care provider leaves the network.


Continuity of Care Form for Plans that Include Tiered-Provider and Limited Provider Networks
Esketamine Nasal Spray and Intravenous Ketamine for Treatment Resistant Depression: Prior Authorization 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
Contract Updates
Contract Update Form for Physician Assistants and Ancillary Advanced Practice Nurses
Update Form for Facilities

Ancillary institutional providers use this form to notify us of contractual or non-contractual changes.


Contract Update Form for Ancillary Professional Providers
Contract Update Form for Behavioral Health Professionals
Contract Update Form for NP-PCPs and PA-PCPs
Contract Update Form for Physicians
Medical Practice Request to Add Medicare Advantage
Acupuncturist updates to add Medicare Advantage
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.


Insurance Attestation Form

Submit this form when credentialing or recedentialing to attest that you maintain the required minimum professional liability (malpractice) insurance of $1M/$3M coverage.


Recredentialing Application for Dentists and Oral Surgeons
HCAS Enrollment Form (hcasma.org)
Public Health Emergency Credentialing Application
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.