Resources and Forms

Resources and Forms

Prior authorization and nonformulary requests includes:

• Formulary information
• Prior authorization drug request form
• Nonformulary drug and tier exception request form
• Provider vaccine form (coming soon)
• Intermediary vaccine form (coming soon)
• Behavioral health (mental health / substance use disorder) fax forms:
  PLEASE NOTE: The fax forms below are for services in January 1, 2020 and later, and only apply to Blue Medicare HMO and Blue Medicare PPO
  • Electroconvulsive Therapy (ECT) 
  • Inpatient Psychiatric Care 
  • Psychological and Neuropsychological Testing 
  • Transcranial Magnetic Stimulation (TMS) 
     
• Experience Health Medicare Advantage ^SM (HMO) Behavioral health inpatient mental health / substance use disorder fax form:
  PLEASE NOTE: The fax form below is for services in January 1, 2020 and later:
  • Inpatient Psychiatric Care Request Form 
     

• Diagnostic Imaging Management Program
   
• Certain durable medical equipment fax forms:
  • Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO) PA Request Form 
  • Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea PA Request Form 
  • Bi-level Positive Airway Pressure (BIPAP) for Treatment of Breathing Related Sleep Disorders PA Request Form 
  • Bi-Level Positive Airway Pressure with Backup Rate (BIPAP ST) for Treatment of Breathing Related Sleep Disorders PA Request Form 
  • Continuous Positive Airway Pressure (CPAP) Rental or Purchase Prior Authorization (PA) Request Form 
  • Durable Medical Equipment (DME) Repair or Replacement Prior Authorization (PA) Request Form 
  • Hospital Bed PA Request Form 
  • Knee Orthosis PA Request Form 
  • Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) PA Request Form 
  • Negative Pressure Wound Therapy (NPWT) Pump Rental PA Request Form 
  • Non-invasive Home Ventilator PA Request Form 
  • Oxygen PA Request Form 
  • Standard Wheelchair PA Request Form 
     
• Experience Health Medicare Advantage ^SM (HMO) durable medical equipment fax forms:
  • Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO) Prior Authorization (PA) Request Form 
  • Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea Prior Authorization (PA) Request Form 
  • Bi-level Positive Airway Pressure (BIPAP) for Treatment of Breathing Related Sleep Disorders Prior Authorization (PA) Request Form 
  • Bi-Level Positive Airway Pressure with Backup Rate (BIPAP ST) for Treatment of Breathing Related Sleep Disorders Prior Authorization (PA) Request Form 
  • Continuous Positive Airway Pressure (CPAP) Rental or Purchase Prior Authorization (PA) Request Form 
  • Hospital Bed Prior Authorization (PA) Request Form 
  • Knee Orthosis Prior Authorization (PA) Request Form 
  • Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) Prior Authorization (PA) Request Form 
  • Negative Pressure Wound Therapy (NPWT) Pump Rental Prior Authorization (PA) Request Form 
  • Non-invasive Home Ventilator Prior Authorization (PA) Request Form 
  • Oxygen Prior Authorization (PA) Request Form 
  • Durable Medical Equipment (DME) Repair or Replacement Prior Authorization (PA) Request Form 
  • Standard Wheelchair Prior Authorization (PA) Request Form 

Provider Manual

The Provider Manual is a complete source for information on working with Blue Medicare HMO and Blue Medicare PPO.

Medicare Payer Sheets
View or download printable Medicare payer sheets.

Diabetes Prevention Program 
Download a Patient Referral Form to record your patient’s current lab results. Submit these to Solera Health to enroll a patient in this program.

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Blue Cross and Blue Shield of North Carolina is an HMO, PPO, and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.