Download Forms for Group Markets

Here are some commonly used forms and documents producers need for conducting business with Blue Cross and Blue Shield of Montana. To access more downloadable forms, please log in to your Blue Access for Producers account.

Using PDFs
Most of the forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®. Other Adobe accessibility tools and information can be downloaded at access.adobe.com.

“Sign Now” Documents
Some documents have a “sign now” option. To review and sign a document now electronically, select the sign now version. If you need to sign a document later, select the download version. These are available in PDF format and some may also be available in Microsoft Word format.
 

Forms for Small Groups (2-50 Employees)

Form Name

Digital Form

Download

2024 Enrollment Package for New Small Groups
Includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/24 and after.

sign now

N/A

2024 Small Group Enrollment Application/Change Form
Use this form to apply for small group coverage effective January 1, 2024.

 N/A

download form

2024 Small Group Enrollment Application/Change Form - Spanish

 N/A

download form

2024 Benefit Program Application (BPA) for New Small Groups
For new accounts effective January 1, 2024.

sign now

download form Microsoft Word Document
download form

2024 Benefit Program Application (BPA) Amendment for Renewing Small Groups
For renewing accounts with anniversary dates after January 1, 2024; use this form to amend the original BPA.

sign now

download form Microsoft Word Document
download form
2024 Important Benefit Changes/Uniform Modification Notice
Identifies some of the most important benefit plan changes for the 2024 coverage year.		 N/A download notice

2023 Enrollment Package for New Small Groups
Includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/23 and after.

sign now

N/A

2023 Benefit Program Application (BPA) for New Small Groups
For new accounts effective January 1, 2023.

sign now

download form Microsoft Word Document
download form

2023 Benefit Program Application (BPA) Amendment for Renewing Small Groups
For renewing accounts with anniversary dates after January 1, 2023; use this form to amend the original BPA.

sign now

download form Microsoft Word Document
download form
2023 Important Benefit Changes/Uniform Modification Notice
Identifies some of the most important benefit plan changes for the upcoming 2023 coverage year.		 N/A download notice

Employer Group Information (EGI) Form – this form must be submitted with the BPA

sign now

download form
Affidavit of Domestic Partnership N/A download form

Affidavit of Domestic Partnership Instructions

N/A

download instructions
Average Employee Count (AEC) Form sign now download form

Composite Billing Guide and FAQs
For fully insured accounts (1-50 employees).

N/A

download guide

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA elections if sending enrollment through BCBSMT to BenefitWallet, HealthEquity or HSA Bank.

N/A

download form

Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration.

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download guide
Dependent Student Medical Leave Certification Form N/A download form

Disabled Dependent Authorization Form (for Group Plans)
Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSMT (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).

N/A

download form

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA integration with Flex.

N/A

download form

HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

N/A

download form

HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HealthEquity.

N/A

download form

HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA and/or FSA integration with HSA Bank.

N/A

download form

Initial Premium EFT Payment Form

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download form
Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. sign now download form

Small Group Underwriting Reference Guide

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download guide

Small Group Submission Checklist

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download form

Summary of Benefits and Coverage (SBC) Notice for Small Groups

N/A

download notice

 

Forms for Large Groups (51+ Employees)

Form Name Digital Form Download
2024 Large Group Enrollment Application/Change Form
Use this form to apply for large group coverage effective January 1, 2024.		 N/A  download form
2024 Large Group Enrollment Application/Change Form - Spanish
 N/A  download form
2024 Benefit Program Application (BPA) for Large Groups
For new accounts effective on or after January 1, 2024.		 N/A  download form Microsoft Word Document
download form
2024 Benefit Program Application (BPA) for Managed Care Large Groups
For new accounts effective on or after January 1, 2024.		 N/A  download form Microsoft Word Document
download form
2023–2024 Important Benefit Changes/Uniform Modification Notice
Identifies some of the most important benefit plan changes for the 2023–2024 coverage year.		 N/A download notice
2023 Benefit Program Application (BPA) for Large Groups
For new accounts effective on or after January 1, 2023.		 N/A  download form Microsoft Word Document
download form
2023 Benefit Program Application (BPA) for Managed Care Large Groups
For new accounts effective on or after January 1, 2023.		 N/A  download form Microsoft Word Document
download form
Employer Group Information (EGI) Form
This form must be submitted with the BPA.		 sign now download form
Affidavit of Domestic Partnership N/A download form
Affidavit of Domestic Partnership Instructions N/A download instructions

Consumer Directed Health Accounts Enrollment and Change Form – Use this form to collect employee FSA and/or HRA elections if sending enrollment through BCBSMT to BenefitWallet, HealthEquity or HSA Bank.

 N/A download form

Consumer Directed Health Accounts How-To Set Up Guide – Use this guide to learn details about setting up accounts that include HSA, FSA or HRA with vendor integration.

 N/A download guide
Dependent Student Medical Leave Certification Form N/A download form
Disabled Dependent Authorization Form (for Group Plans)
Members with an employer-sponsored health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSMT (see address and fax number at the top of the form). You can also use this form to add a disabled dependent to a new policy (include this completed form when you submit your enrollment application).		 N/A download form

FSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect FSA and/or HRA integration with Flex.

 N/A download form

HSA Employer Setup Form – Flex – Submit an electronic copy of this form for each employer wishing to elect HSA integration with Flex.

 N/A download form

HSA/FSA Employer Setup Form – HealthEquity® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HealthEquity.

 N/A download form

HSA/FSA Employer Setup Form – HSA Bank® – Submit an electronic copy of this form for each employer wishing to elect HSA, FSA and/or HRA integration with HSA Bank.

 N/A download form
Initial Premium EFT Payment Form sign now download form
Medical Loss Ratio (MLR) Written Assurance Form - Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. sign now download form
Average Employee Count (AEC) Form sign now download form
Merit Group Request for Proposal
This form is completed by Sales Representatives and District Sales Managers with the group's insurance information. This will prompt the Underwriting work area to produce a quote.		 N/A download form
Request for Proposal
Use this form for new groups with 151+ eligible employees.		 N/A download form

 

Medicare Secondary Payer (MSP) Form and Information

Form Name Digital Form Download
Medicare Secondary Payer (MSP) Employer Acknowledgement Form (EAF)
In the absence of employer-provided employee counts, the Centers for Medicare and Medicaid Services (CMS) requires the employer group health insurance plan be considered primary to Medicare. PDF includes the Annual Medicare Secondary Payer Employer Acknowledgement Form and Instructions for completing the form.		 sign now download form

 

Claim Forms

Form Name Digital Form Download
Claim Form – Dental
Use this form to file dental claims for reimbursement that are not filed by your dental provider.		 N/A  download form
Claim Form – Dental (Spanish)
 N/A  download form
Claim Form – Medical (Domestic)
Use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.		 N/A  download form
Claim Form – Medical (International)
Use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.		 N/A  download form
Health Fair, Lab and Immunization Submission Form
Use this form to submit preventative immunization or laboratory services received at a Heath Fair, a City/County Health Department, Pharmacy, etc. Include a receipt or itemized statement.		 N/A download form

 

Miscellaneous Forms

Form Name Digital Form Download
Producer of Record Transfer Form and Instructions N/A download form

 

Legal / HIPAA Forms

Form Name Digital Form Download
Authorization for Release for Medical Records for Underwriting Purposes N/A  download form
Notice of Special Enrollment Rights in Your Group Health Plan N/A download notice
Standard Authorization Form and other HIPAA Privacy Forms N/A access forms

 

Ancillary Products Forms

Download Ancillary Product Forms

Last Updated: March 13, 2024