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.

• Model of Care training (PDF)
• Model of Care attestation form

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)
• Carelon Medical Benefits Management, Inc. Updates Effective December 20, 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 Criteria Updates Effective December 26, 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 
  • Portal
• 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

primetherapeutics.com

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