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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

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Provider Forms

PW_AD051571
 
Behavioral Health Forms 
Psychotherapy Notes Authorization Form

Complete this form for release of psychotherapy notes from Provider to Company. If member wishes to disclose clinical information and psychotherapy notes, member must complete both the Individual Authorization Form and Psychotherapy Notes Authorization Form.

Outpatient Treatment Plan Form
Post Discharge Ambulatory Follow-Up Appointment Authorization Form
Request for Authorization of Psychological Testing
 
Clinical Information Requests 

Use this form to FAX (if 25 pages or less) or MAIL clinical information when filing an initial claim paper claim or if you have received a request for clinical information and you have the claim number to reference.

Requests for Clinical Information Procedure
Clinical Information/Supporting Documentation Form
List of Clinical Submission Categories
 
Fee Schedule Request  
Fee Schedule Request Form

Use this form to EMAIL, FAX or MAIL request for fee schedule information.

Fee Schedule Request Procedure
 
Misc. Forms  
Anthem Care Comparison Facility Self Reported Volume Form
Blue View VisionSM Reimbursement Form
Coordination of Benefits Information Worksheet
Electronic Funds Transfer (EFT) Form
Individual Authorization Form

Complete this form for release of PHI and clinical information from Provider to Company. If member wishes to disclose clinical information and psychotherapy notes, member must complete both the Individual Authorization Form and Psychotherapy Notes Authorization Form.

Medical-Surgical Clinical Data Submissions Tools
Pre-Service Medical Benefit Review for Specialty Drugs
Provider General Correspondence Form

Use this form as a cover page for general correspondence, corrected claims, tracers, new claims, coverage verification and when sending information requested.

Provider Nomination Form
Provider Request for Review Form
Provider Remit Sample
Room Rate Request Form
 
Preventive Care Guidelines  
Use these forms to track preventive care encounters.  
Infant Preventive Flow Sheet
Early Childhood Preventive Care Flow Sheet
Young Child Preventive Care Flow Sheet
Adolescent Preventive Care Flow Sheet
Adult Female Preventive Care Flow Sheet
Adult Male Preventive Care Flow Sheet
Diabetes Patient Care Annual Flow Sheet
Patient-Administered Sexual History Questionnaire
A Guide to Sexual History Taking
 
Provider Appeals  
Policy and Procedure for Provider Appeals Process
 
Provider Information Change (PIC) 
PIC Form

Use this form to FAX or MAIL changes in your practice information (address, locations, billing, new Tax ID Number, etc.). 

PIC User Guide
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.