Blue Cross Blue Shield of Illinois Durable Medical Equipment
Forms
The forms in this online library are updated frequently—check often to ensure you are using the most current versions. Some of these documents are available as PDF files. If you do not have Adobe® Reader®, download it free of charge at Adobe's site. 
Types of Forms
- Appeal/Disputes
- Behavioral Health (Commercial)
- Behavioral Health (Medicaid Only - BCCHP and MMAI)
- Behavioral Health (Medicare Advantage PPO)
- Claim Reporting/Results/Resolution
- Claim Review
- Claim Review (Medicare Advantage PPO)
- Credentialing/Contracting
- Durable Medical Equipment (DME)
- Electronic Access/Enrollment
- Fee Schedule
- Medical Policy (Documentation)
- Member Information/Release Forms
- Network Participation/Provider Updates
- Pharmacy
- Pre-service Review
- Wellness
Appeal/Disputes
| Form Title | Network(s) |
|---|---|
| Expedited Pre-service Clinical Appeal Form | Commercial only |
| Medicaid Claims Inquiry or Dispute Request Form | Medicaid only (BCCHP and MMAI) |
| Medicaid Service Authorization Dispute Resolution Request Form | Medicaid only (BCCHP and MMAI) |
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Behavioral Health (Commercial)
| Form Title | Network(s) |
|---|---|
| Applied Behavior Analysis (ABA) Clinical Service Request Form | Commercial only |
| Applied Behavior Analysis (ABA) Initial Assessment Request Form | Commercial only |
| Coordination of Care Form | All Networks |
| Electroconvulsive Therapy (ECT) Request Form | Commercial only |
| Intensive Outpatient Program (IOP) Request Form | Commercial only |
| Psychological/Neuropsychological Testing Request Form | Commercial only |
| Repetitive Transcranial Magnetic Stimulation (rTMS) | Commercial only |
| Transitional Care Request Form | Commercial only |
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Behavioral Health ( Medicaid Only - BCCHP and MMAI )
| Form Title | Network(s) |
|---|---|
| Applied Behavior Analysis - Clinical Service Request Form | Medicaid only |
| Applied Behavior Analysis - Initial Assessment Request | Medicaid only |
| Community Based BH Request Form | Medicaid only |
| Electroconvulsive Therapy (ECT) Request Form | Medicaid only |
| Fax Coversheet | Medicaid only |
| Psychological/Neuropsychological Testing Request Form | Medicaid only |
| Transcranial Magnetic Stimulation (rTMS) Request Form | Medicaid only |
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Behavioral Health (Medicare Advantage PPO)
| Form Title | Network(s) |
|---|---|
| Electroconvulsive Therapy (ECT) Request Form | Medicare Advantage PPO |
| Psychological/Neuropsychological Testing Request Form | Medicare Advantage PPO |
| Transcranial Magnetic Stimulation (rTMS) Request Form | Medicare Advantage PPO |
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Claim Reporting/Results/Resolution
| Form Title | Network(s) |
|---|---|
| Check and Voucher Request Form | Commercial only |
| Medicare Reconsideration Form | Commercial only |
| Provider Refund Form | Commercial (professional only) |
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Claim Review
| Form Title | Network(s) |
|---|---|
| Additional Information Claim Form | Commercial only |
| Claim Review Form | Commercial only |
| Corrected Claim Form | Commercial only |
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Claim Review (Medicare Advantage PPO)
| Form Title | Network(s) |
|---|---|
| Claim Review (Medicare Advantage PPO) | Medicare Advantage PPO only |
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Credentialing/Contracting
| Form Title | Network(s) |
|---|---|
| Attestation for Provider Credentialing | Commercial, MA HMO, MA PPO and MMAI |
| Hospital Coverage Letter - Updates in progress | Commercial, MA HMO, MA PPO and MMAI |
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Durable Medical Equipment (DME)
| Form Title | Network(s) |
|---|---|
| Durable Medical Equipment (DME) Benefit Limits Verification Request Form | Medicaid only (BCCHP and MMAI) |
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Electronic Access/Enrollment
| Form Title | Network(s) |
|---|---|
| HMO Online Access Request Form | HMO Commercial and MA HMO |
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Fee Schedule
| Form Title | Network(s) |
|---|---|
| Fee Schedule Request - BlueChoice PPO SM | Commercial Only |
| Fee Schedule Request - PPO | Commercial Only |
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Medical Policy (Documentation)
| Form Title | Network(s) |
|---|---|
| Hyperbaric Oxygen (HBO) Pressurization Form | All Networks |
| Wheelchair Medical Necessity and Home Evaluation Verification Form | All Networks |
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Member Information/Release Forms
| Form Title | Network(s) |
|---|---|
| Behavioral Health Release of Information Form - Sample | All Networks |
| COB Questionnaire | All Networks |
| Dependent Student Medical Leave Form | All Networks |
| Standard Authorization Form to Use or Disclose PHI | All Networks |
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Network Participation/Provider Updates
| Form Title | Network(s) |
|---|---|
| Demographic Change Form | All Networks |
| Provider Onboarding Form | All Networks |
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Pharmacy
| Form Title | Network(s) |
|---|---|
| Refer to the Pharmacy Program section for more information. | All Networks |
| Uniform Prior Authorization Form | Commercial Only |
| Synagis Prior Authorization Form | Medicaid (BCCHP only) |
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Pre-service Review
| Form Title | Network(s) |
|---|---|
| Medicaid Prior Authorization Request Form | Medicaid only (BCCHP and MMAI) |
| Predetermination Request Form | Commercial, non-HMO |
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Wellness
| Form Title | Network(s) |
|---|---|
| Medicare Advantage Annual Wellness Visit Form | Medicare Advantage Plans |
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Source: https://publicsitesil.hcsc.net/provider/forms/
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