Provider Forms and Documents
- Advanced Member Notice . Advance Member Notification refers to the process in which a provider informs a member that a service, supply, device, or drug is not likely to be considered for compensation by BCBSMT prior to the service being performed.
- Authorization for Disclosure of Individual's Health Information or the Standard Authorization Form (SAF) . Use this form to authorize BCBSMT to disclose information to another person or entity.
- BlueCard Worldwide International Claim Form . For Members traveling out of the country for medical services, this form must be completed after having services in a hospital, treated by a professional medical provider, or medical vision services.
- Change of Status Form (Provider) . Use this form to notify Health Care Services of changes to your address, telephone, tax ID, and any other information used to process BCBSMT claims.
- Corrected Claim or Claim Review Request Form . Use this form to correct a previously submitted claim or to ask for a review of a denied claim.
- Claim Form For The Blue Cross and Blue Shield Parties' Settlement Fund and Election of Contribution to Charitable Foundation or Organization . Instructions
- CMS-1500 Claim Form (Version 02/12) . Instructions for completing CMS-1500 Form (Version 02/12) . Professional Providers use this form to request compensation for medical services. Print and use this form in color so our optical character recognition scanner can read your claim.
- UB-04 Claim Form . Hospitals and facilities use this form to request compensation for medical services. Print and use this form in color so our optical character recognition scanner can read your claim. Use the UB-04 User Guide document to learn how to complete the UB-04 Claim Form.
Additional program information coming soon.
- Behavioral Health Coordination of Care Form
- Electroconvulsive Therapy (ECT) Request Form
- Intensive Outpatient Program (IOP) Request Form
- Transitional Care Request Form
- Clinical Update Request
- Repetitive Transcranial Magnetic Stimulation (rTMS) Request Form
- Psychological or Neuropsychological Testing Form
Physicians can access, complete and submit Prior Authorization and Step Therapy request forms electronically from the CoverMyMeds® website:
- Prescription Drug Form . Use this form to request reimbursement when your drug benefit is processed directly through BCBSMT rather than through a third party Pharmacy Benefit Manager.
- PrimeMail New Prescription Order Form
- PrimeMail Refill Prescription Order Form
- Prime Reimbursement Claim Form
- Ridgeway Mail Order Form
- NDC Reimbursement Schedule Request Form
Pharmacy Predetermination Physician Fax Forms:
Prime Specialty Pharmacy Referral:
- Family Building
- General Use Fax Form
- Growth Hormone Therapy
- Hepatitis C/HCV
- Multiple Sclerosis
- Rheumatoid Arthritis
- Prime Specialty Pharmacy Program Drug List
Predeterminations (formerly called Prior Authorization) and Pre-Authorization/Precertification
- Predetermination General Interactive Form . Predetermination is a process BCBSMT uses to make coverage decisions in accordance with medical policy and group or member contracts for a service, supply, drug, or device used to diagnose or treat an illness or condition.
- Predetermination DME Provider Interactive Form . If the purchase price over $1000, complete this form. If the purchase price is $500 or greater, call Customer Service at 800-447-7828 to determine if predetermination is necessary. If predetermination is necessary, complete this form. Specific coverage criteria for some items are explained in medical policy published at www.bcbsmt.com or in the member's contract.
- Predetermination Medicare Advantage Provider Interactive Form . This form is specific to BCBSMT Medicare Advantage Medical benefits. Providers should complete this form and fax it to 855-874-4711.
- Patient Assessment Validation Evaluation Form . To be used when requesting Lower extremity prosthetic limbs. Use this form to complete a Patient Assessment Validation Evaluation Test
- Genetic Testing Provider Interactive Form . Requested to be used when requesting genetic testing.
- Certification for Admission Provider Interactive Form . Pre-authorization form to capture all required key data for Pre-authorization, additional information can be found here.
- Wheelchair Medical Necessity-Home Evaluation Provider Interactive Form . To be used when requesting wheelchairs and accessories.
- Healthy Montana Kids (HMK) - DME Form . This form is specific to HMK DME benefits and is used for providers to request predetermination DME services for HMK members.
- Healthy Montana Kids (HMK) - General Form . This form is specifically for providers to request predetermination services for HMK members.
- Healthy Montana Kids (HMK) - Hearing Aids Form . This form is specific to HMK hearing aid benefits and is used for audiologists to request predetermination hearing aids and related supplies.