Provider Central

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
Continuity/Transition of Care Request
Massachusetts Standard Form for Applied Behavior Analysis Services Prior Authorization Requests (masscollaborative.org)
Behavioral Health Level of Care Form

This file combines the Blue Cross cover sheet with the Mass Collaborative form.

Automatic Fax-Back Program: Request Form

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

Pre-Authorization for Non-Emergent Ground Ambulance Transport
Pre-Certification / Pre-Authorization Request
Psychological and Neuropsychological Assessment Form

This file combines the Blue Cross cover sheet with the Mass Collaborative form.

Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form

This file combines the Blue Cross cover sheet with the 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
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
Updates to Existing Authorizations
Bone Mineral Density Order Form
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 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
PA-PCP and NP-PCP Contracting Application
Physical Therapist, Occupational Therapist, and Speech Language Pathologist Contracting Application
Podiatrist (DPM) Contracting Application
Behavioral Health Nurse and Physician Assistant 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
NP Contracting Application
Update Form for Facilities (with instructions)
Request for Consent to Assignment of Provider Contracts

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

Contract Update Form for Physician Assistants and Ancillary Advanced Practice Nurses
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
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)
Prior Authorization Request for Medically Necessary Orthodontia Services for Pediatric Essential Health Benefits
Handicapping Labio-Lingual Deviations (HLD Index 4)
Enhanced Dental Benefit Enrollment Form

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

ADA Claim Form
Dental Blue 65 Enhanced Dental Benefit Enrollment Form
Request for Dental Claim Review
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
Request for Dental Claim Review
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.

Independent Dispute Resolution
No Surprises Act (NSA) Open Negotiation Form and Instructions