Annually, a representative from each provider’s practice and/or facility must attest to completing the Special Needs Plans (SNPs) and Model of Care overview. Representatives must complete an attestation form at the end of training.
If you have an issue with completing the attestation form online after reviewing the Model of Care training, you can print a copy of the form, complete all required information and fax to 919-765-7109. You can also submit via email to DSNP_ProviderAttestations@bcbsnc.com.
All claims for Healthy Blue + Medicare members must be filed through Availity. You can learn more about using Availity by visiting the Training and Education page.
Do not submit Healthy Blue + Medicare HMO D-SNP claims through Blue e provider portal.
These forms are specific to Healthy Blue + Medicare HMO D-SNP and are required when doing business with Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Please complete forms related to pre-certification, behavioral health treatment, and other similar cases before rendering service.
- Behavioral Health Concurrent Review Fax Form (PDF)
Please complete for any concurrent review. - Behavioral Health Discharge Note (PDF)
Form provides information when member will be discharged from behavioral health treatment. - Electroconvulsive Therapy Prior Authorization Request (PDF)
ECT services require prior authorization and form must be submitted prior to rendering treatment. - General Precertification Request (PDF)
Form can be used to request prior authorization for inpatient admissions. - Initial Note Review (PDF)
Request for an initial case for behavioral health. - Mental Health Outpatient Treatment Report (PDF)
Services require prior authorization and form must be completed prior to rendering treatment. - Neuropsychological Testing (PDF)
Request for Authorization-services require prior authorization and form must be submitted prior to rendering treatment. - Overpayment Refund Notification Form (PDF)
Please complete this form when refunding money and include all necessary documentation. - Psychological Testing Request for Authorization
Services require prior authorization and form must be completed prior to rendering treatment. - Recoupment Authorization Form (PDF)
Please complete this form and mail with supporting documentation authorizing adjustments to be offset / recouped from future claims payments, do not enclose a check for the amount to be refunded when submitting this form. - Transcranial Magnetic Stimulation (TMS) Request Form (PDF)
Please complete this form in its entirety and submit for prior review when rendering TMS services.
- 2025 Clinical Quality in Practice Webinar Series (PDF)
- Addressing Medication Adherence Gaps (PDF)
- Admission, Discharge, And Transfer Information Is Now Available for Medicare Advantage Members (PDF)
- Advanced Illness and Frailty Exclusions (PDF)
- Advanced Illness and Frailty Exclusions 2025 (with coding) (PDF)
- Advancing Digital Efficiency by Discontinuing Paper Remittances (PDF)
- Adult Immunization Status (AIS-E) (PDF)
- Announcing Health Perks — Earn Rewards for Your Healthcare Activities (PDF)
- A Quick Guide to Understanding JW and JZ Modifiers (PDF)
- Benefits of Utilization Management Attestations: A Guide from Providers (PDF)
- Blood Pressure Control for Patients With Diabetes (BPD) 2025 (PDF)
- Blue Cross and Blue Shield of North Carolina Expands Specialty Pharmacy Recertification List (August 2024 Pt. 2) (PDF)
- Blue Cross NC Expands Specialty Pharmacy Precertification Lists (PDF)
- Breast Cancer Screening (BCS-E) (PDF)
- Bridging The Gap: Enhancing Medication Adherence For Better Health (PDF)
- Cardiac Rehabilitation (CRE) 2025 (PDF)
- Care for Older Adults (COA) 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective September 2024 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective February 8, 2025 (PDF)
- Carelon Medical Benefits Management, Inc Updates Effective March 23, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective July 1, 2025 (PDF)
- Carelon Medical Benefits Management, Inc Updates Effective July 15, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. updates effective July 26, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates effective October 1, 2025 (PDF)
- Carelon Medical Benefits Management,Inc. Updates Effective November 14, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective November 15, 2025 (PDF)
- Claims Guidance: Updating Inpatient And Outpatient Bill Types (PDF)
- Clarification to Carelon Medical Benefits Management, Inc. Updates Effective September 1, 2024 (PDF)
- Clinical Criteria Updates Effective October 12, 2024 (PDF)
- Clinical Criteria Updates Effective January 31, 2025 (PDF)
- Clinical Criteria Updates Effective February 17, 2025 (PDF)
- Clinical Criteria Updates Effective May 4, 2025 (PDF)
- Clinical Criteria Updates Effective May 27, 2025 (PDF)
- Clinical Criteria Updates Effective May 28, 2025 (PDF)
- Clinical Criteria Updates Effective September 4, 2025 (PDF)
- Clinical Criteria Updates Effective September 13, 2025 (PDF)
- Clinical Criteria Updates Effective October 27, 2025 (PDF)
- Clinical Criteria Updates Effective December 19, 2025 (PDF)
- Clinical UM Attestation and Use Guide - FAQ (PDF)
- Coding Validation Expansion: Medicare (PDF)
- Colorectal Cancer Screening (COL-E) (PDF)
- Controlling High Blood Pressure (CBP) 2025 (PDF)
- Depression Screening and Follow-up for Adolescents and Adults (DSF-E) (PDF)
- Drug and Biologic (PDF)
- Efficiency and the Check-in Experience with Digital Member ID Cards (PDF)
- Elevate your practice efficiency with electronic prescriber tools (PDF)
- Elevate your workflow with seamless patient chart uploads (PDF)
- Enhance Billing and Coding Accuracy with New Payment Integrity Training (PDF)
- Enhance Billing and Coding Accuracy with New Payment Integrity Training Updates (PDF)
- Enhance Patient Coordination with Total Member View (PDF)
- Enhance Your Skills with Expanded Billing and Coding Training (PDF)
- Enhancing Patient Safety Through Medication Monitoring Enhance (PDF)
- Expanded Specialty Pharmacy Precertification List Effective Date November 1, 2025 (PDF).
- Eye Exam for Patients with Diabetes (EED) 2025 (PDF)
- Follow-up After Emergency Department Visit for Patients With Multiple High-Risk Chronic Conditions (FMC) (PDF)
- Glycemic Status Assessment for Patients with Diabetes (GSD) 2025 (PDF)
- Heart Health Spotlight: Leveraging Statin Therapy for Diabetes (PDF)
- HEDIS 2024 Documentation for Care of Older Adults (COA) (PDF)
- HEDIS 2024 Documentation for Colorectal Cancer Screening (COL-E) (PDF)
- HEDIS 2024 Documentation for Controlling High Blood Pressure (CBP) and Statin Therapy for Patients with Cardiovascular Disease (SPC) (PDF)
- HEDIS 2024 Updates: Advanced Illness and Frailty Exclusions (PDF)
- HEDIS CAT II Coding Bulletin 2025 (PDF)
- HEDIS Measure: Statin Use in Persons with Diabetes (SUPD) 2025 (PDF)
- HEDIS Measure Tips — Adults’ Access to Preventive/Ambulatory Health Services (AAP) 2025 (PDF)
- HEDIS Measure Tips — Appropriate Testing for Pharyngitis (CWP) 2025 (PDF)
- HEDIS Measure Tips — Appropriate Treatment for Upper Respiratory Infection (URI) 2025 (PDF)
- HEDIS Measure Tips — Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) 2025 (PDF)
- HEDIS Medical Record Submission — Easier with Remote EMR Access Service (PDF)
- HEDIS Transitions of Care (TRC) (PDF)
- Health Outcomes Survey (PDF)
- Health Outcomes Survey: Fall Risk Management (FRM) (PDF)
- Health Outcomes Survey: How to Improve the Patient Experience (PDF)
- Health Outcomes Survey: Management of Urinary Incontinence in Older Adults (MUI) (PDF)
- Health Outcomes Survey: Physical Activity in Older Adults (PAO) (PDF)
- ICD-10-CM Excludes1 Notes (PDF)
- Important Change to Your Patients’ Specialty Prescriptions (PDF)
- Important Information About Specialty Prescriptions (PDF)
- Important HEDIS Supplemental Data Submission Dates and Deadlines (PDF)
- Improving Patient Outcomes: Back to the Basics (PDF)
- Kidney Health Evaluation for Patients With Diabetes (KED) 2025 (PDF)
- Kroger Specialty Pharmacy Acquisition (PDF)
- MCG Care Guidelines 29th Edition (PDF)
- Medical Policies and Clinical UM Guidelines
- Medical Policies and Clinical Utilization Management Guidelines Update Effective December 10, 2024 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective February 13, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective June 15, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective August 5, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective October 24, 2025 (PDF)
- Medical Policy and Clinical Utilization Management Guidelines Website Instructions (PDF)
- Medicare Part B Preapproval Expands with New Drug Additions (PDF)
- Medicare Part D Overhaul: What's New in 2025 for Your
- Medication Adherence 2025 (PDF)
- Medication Safety: Reducing Risks with Thoughtful Prescribing and Monitoring (PDF)
- Medicare Risk Adjustment Provider Documentation and Coding Guide (PDF)
- National Drug Codes (NDC) Are Required for Outpatient Claims (PDF)
- National Drug Codes (NDCs) Are Required for Professional and Outpatient Claims (PDF)
- New Reimbursement Policy: New Genetic Tests: Once Per Lifetime (PDF)
- New Specialty Pharmacy Medical Step Therapy Requirement (PDF)
- New Specialty Pharmacy Medical Step Therapy Requirements (July 1, 2025) (PDF)
- North Carolina 2025 Medicare Advantage Plan Changes (PDF)
- Notice of Change: Part D Rx HCCs (PDF)
- Osteoporosis Management in Women Who Had a Fracture (OMW) (PDF)
- Osteoporosis Screening in Older Women (OSW) (PDF)
- Outcomes Combat Diabetes: Close the Statin Therapy Gap for Better Heart Health (PDF)
- Personalized Match Update (PDF)
- Preventing Flu: Drive the Change Through Vaccination (PDF)
- Pharmacotherapy Management of COPD Exacerbation (PCE) 2025 (PDF)
- Pharmacy Clinical Criteria
Clinical criteria documents for all injectable, infused or implanted prescription drugs and therapies covered under the Healthy Blue + Medicare medical benefit (Part C). - Phishing Scam Alert - Impersonating CMS (PDF)
- Policy Update - Nurse Practitioner and Physician Assistant Services (PDF)
- Prescription Drug Costs? (PDF)
- Precertification/Prior Authorization Requirement Changes Effective December 1, 2025 (PDF)
- Precertification/Prior Authorization Requirement Changes Effective January 1, 2026 (PDF)
- Prevent Flu and COVID-19: Drive the Change Through Vaccination (PDF)
- Prior Authorization Requirement Changes Effective December 1, 2024 (PDF)
- Prior Authorization Requirement Changes Effective January 1, 2025 (PDF)
- Prior Authorization Requirement Changes Effective February 1, 2025 (PDF)
- Prior Authorization Requirement Changes Effective July 1, 2025 (PDF)
- Prior Authorization Requirement Changes Effective July 1, 2025 (Additional changes) (PDF)
- Prior Authorization Requirement Changes Effective November 1, 2025 (PDF)
- Provider Manual (PDF)
- Real-Time Prescription Benefit (PDF)
- Resources to Support Diverse Patients and Communities (PDF)
- Seamless Advance Care: MyDirectives Digital Tool for D-SNP Members (PDF)
- Shortage of Repackaged Bevacizumab for Ophthalmic Use (PDF)
- Skilled Nursing Facility — Vaccine Serum Compensation (PDF)
- Specialty Pharmacy Preapproval List Update (PDF)
- Specialty Pharmacy Precertification List Expansion (Effective April 1, 2025) (PDF)
- Specialty Pharmacy Precertification List Expansion — Key Updates (PDF)
- Specialty Pharmacy Precertification List Expanded (PDF)
- Specialty Pharmacy Precertification List Expanded Effective December 1, 2025 (PDF)
- Specialty Pharmacy Precertification and Step Therapy List Expansion (Effective April 1, 2025) (PDF)
- Social Need Screening and Interventions (SNS-E)
- Statin Therapy for Patients with Cardiovascular Disease (SPC) 2025 (PDF)
- Streamlining Behavioral Health Authorizations via Availity Essentials (PDF)
- Submitting BH Authorizations in Availity Essentials (PDF)
- Time to Prepare for HEDIS Medical Record Review (PDF)
- Understanding Your Role in the Health Outcomes Survey (PDF)
- Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines Effective October 20, 2024 (PDF)
- Use Availity Essentials to View Authorization Case Status and Set Authorization Decision Notification Preference (PDF)
- Abortion (Termination of Pregnancy) (PDF)
- Claims Submission - Required Information for Facilities (PDF)
- Claims Submission – Required Information for Professional Providers (PDF)
- Claims Timely Filing (PDF)
- Code and Clinical Editing Guidelines (PDF)
- Consultations (PDF)
- Corrected Claims (PDF)
- Diagnosis-Related Group (DRG) Inpatient Facility Transfers (PDF)
- Diagnosis Used in DRG Computation (PDF)
- Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) (PDF)
- Documentation Standards for Episodes of Care (PDF)
- Drug Screen Testing (PDF)
- Duplicate or Subsequent Services on the Same Date of Service (PDF)
- Durable Medical Equipment (Rent to Purchase) (PDF)
- Eligible Billed Charges (PDF)
- Emergency Department Leveling of Evaluation and Management Services (PDF)
- Emergency Services: Nonparticipating Providers and Facilities (PDF)
- Facility Take-Home DME and Medical Supplies (PDF)
- Genetics Tests: Once per Lifetime (PDF)
- Global Surgical Package (PDF)
- Hysterectomy (PDF)
- Inpatient Readmissions (PDF)
- Maternity Services (PDF)
- Maximum Units Per Day (PDF)
- Medical Recalls (PDF)
- Modifier 22 (PDF)
- Modifier 24 (PDF)
- Modifiers 25 and 57 (PDF)
- Modifiers 26 and TC (PDF)
- Modifiers 50 and 51 (PDF)
- Modifier 63 (PDF)
- Modifier 66 (PDF)
- Modifier 76: Repeat Procedure by the Same Physician (PDF)
- Modifier 77 (PDF)
- Modifier 78 (PDF)
- Modifiers 80, 81, 82, and AS: Assistant at Surgery (PDF)
- Modifier 90 (PDF)
- Modifier 91 (PDF)
- Modifiers LT and RT (PDF)
- Modifier Usage (PDF)
- Multiple Delivery Services (PDF)
- Multiple Procedure Payment Reduction (PDF)
- Multiple Radiology Payment Reduction (PDF)
- Nurse Practitioner and Physician Assistant Services (PDF)
- Portable/Mobile/Handheld Radiology Services (PDF)
- Preadmission Services for Inpatient Stays (PDF)
- Preventive Medicine and Sick Visits on the Same Day (PDF)
- Professional Anesthesia Services (PDF)
- Proof of Timely Filing (PDF)
- Prosthetic and Orthotic Devices (PDF)
- Provider Preventable Conditions (PDF)
- Reduced and Discontinued Policies (PDF)
- Reimbursement for Items under Warranty (PDF)
- Reimbursement Policies Disclaimer (PDF)
- Reimbursement Policies Overview (PDF)
- Sanctioned and Opt-Out Providers (PDF)
- Split Care Surgical Modifiers (PDF)
- Sterilization (PDF)
- Technology Assisted Surgical Procedures (PDF)
- Transportation Services: Ambulance and Nonemergent Transport (PDF)
- Unlisted and Miscellaneous Codes (PDF)

Healthy Blue + Medicare customer service
PO Box 62947
Virginia Beach, VA 23466
Phone: 833-713-1078
Fax: 855-358-1226
Attention: Medical Necessity Provider Appeals
Mailstop: OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040
Phone: 833-713-1078
Fax: 888-458-1406
Prime Therapeutics
Medicare Appeals Department
10802 Farnam Dr.
Omaha, NE 68154
Phone: 800-725-7710
For difficulties with hearing or speaking, please call 800-693-6703.
Fax: 888-285-2242
Phone: 844-895-8160
Fax: 877-799-4129
Healthy Blue + Medicare
PO Box 60007
Los Angeles, CA 90060-0008
Phone: 866-611-4287
Fax: 855-443-7821
Healthy Blue + Medicare
3350 Peachtree Road NE
Atlanta, GA 30326