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Administrative
PDF icon 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).


PDF icon Clinical Criteria Request Form


Electronic Remittance Advice Enrollment Form (Submit Online)
PDF icon 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
PDF icon Referral for Health Management Programs & Services
PDF icon Paper Remittance Copy Request
PDF icon Continuity/Transition of Care Request
PDF icon 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.


PDF icon 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.


PDF icon 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
PDF icon Continuity/Transition of Care Request
PDF icon 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
PDF icon Automatic Fax-Back Program: Request Form
PDF icon Universal Home Health Authorization Form
PDF icon 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.


PDF icon Psychological and Neuropsychological Assessment Supplemental Form

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


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

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


PDF icon 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.

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


PDF icon Managed Care Out-of-Network Request Form
PDF icon 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
PDF icon Medicare Part D Coverage Determination Request Form

For Medicare prior authorization or formulary exception requests


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


PDF icon Contract Update Form for Ancillary Professional Providers

Behavior Analysts, please use the form for Ancillary Professionals.


PDF icon Contract Update Form for Behavioral Health Professionals
PDF icon Contract Update Form for NP-PCPs and PA-PCPs
PDF icon Contract Update Form for Physicians
PDF icon 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
PDF icon 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.


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


PDF icon TDI Privileging Application

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


PDF icon Privileging Exception Request Form
Review & Appeals
PDF icon Coordination of Benefit Questionnaire
PDF icon Non-Covered Service Waiver
PDF icon 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.


PDF icon Open Negotiation Notice

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