Healthy Blue + Medicare HMO D-SNP

Model of Care training

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.

Submit claims with Availity®

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.

Forms

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 (PDF)
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.

Resources

Reimbursement policies

Sample member ID cards

Blue Cross NC sample of Healthy Blue + Medicare cards - front and back

Contact information

Healthy Blue + Medicare customer service

PO Box 62947
Virginia Beach, VA 23466

Phone: 833-713-1078
Fax: 855-358-1226

Medicare complaints, appeals & grievances (medical and drugs Part C)

Attention: Medical Necessity Provider Appeals

Mailstop: OH0205-A537
4361 Irwin Simpson Road
Mason, OH 45040

Phone: 833-713-1078
Fax: 888-458-1406

For coverage decisions and appeals for Part D drugs

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

Provider services (medical & drug)

Phone: 844-895-8160
Fax: 877-799-4129

Healthy Blue + Medicare
PO Box 60007
Los Angeles, CA 90060-0008

Case management (medical & drug)

Phone: 866-611-4287
Fax: 855-443-7821

Healthy Blue + Medicare
3350 Peachtree Road NE
Atlanta, GA 30326