Healthy Blue + Medicare HMO D-SNP

These forms are specific to Healthy Blue + Medicare HMO D-SNP and are required when doing business with 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.

• Overview of Medicaid with Healthy Blue® and Medicare Advantage with Healthy Blue + Medicare℠ (HMO D-SNP) (PDF)
  Blue Cross NC has developed a Healthy Blue and Healthy Blue + Medicare overview highlighting key points about each product. This overview provides important details about each product, the differences between each product and will assist providers in administering both products for our members appropriately.
• Availity: Medicare provider-facing talking points and FAQ (PDF)
• Availity Portal Overview (PDF)
• Blue Cross NC and Anthem Collaboration
• Care Part B Expansion Adstiladrin, Altuviiio, Idacio, Lamzede, Lunsumio, Rebyota, Signifor LAR, Syfovre, Vivimusta (PDF)
• Clinical Criteria Updates November 2022 Healthy Blue + Medicare (HMO D-SNP) (PDF)
• Clinical Criteria Updates - March 2023 (PDF)
• Clinical Criteria Updates - May 2023 (PDF)
• Clinical Laboratory Improvement Amendments (PDF)
• Conducting the Medicare Annual Wellness Visit Via Telehealth: Guide for Office, Nursing and Provider Staff (PDF)
• Electronic Data Interchange Overview (PDF)
• How to Navigate Patient360 through the Availity Portal (PDF)
• Healthy Blue + Medicare D-SNP Supplemental Guide (PDF)
  
• Heart Healthy Diets: A Collaborative Approach Between Provider and Patient (PDF)
• Improving the Patient Experience (PDF)
• Itemized Bill Review Program (PDF)
• Medical Policies and Clinical UM Guidelines 
  • Portal
  • Instructions (PDF)
• Medical Policies and Clinical Utilization Management Guidelines Update (PDF)
• Medical Step Therapy - Rituxan Agents (PDF)
• Medicare Advantage Skilled Nursing Facility/Rehabilitation Pre-Certification Worksheet (PDF)
• Medicare Annual Wellness Visit Workflow (PDF)
• Medicare Medical Precertification Expansion (PDF)
• Medicare Part B Precert Expansion Imjudo, Pedmark, Tecvayli, Tzield, Vegzelma (PDF)
• Medicare Risk Adjustment Provider Documentation and Coding Guide (PDF)
• MCG Care Guidelines 27th Edition (PDF)
  
• Personalized Match Phase 1 (PDF)
• Personalized Match Phase 1: Specialist Provider Overview (PDF)
• Pharmacotherapy Management of COPD Exacerbation HEDIS Measure (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).
• Prior Authorization Requirement Changes Effective August 1, 2023 (PDF)
• Prior Authorization Requirement Changes Effective November 1, 2023 (PDF)
• Prior Authorization Requirement Changes Effective December 1, 2023 (PDF)
• Providing a Superb Patient Experience (PDF)
• Providing Preventive Care in an Urgent Care Setting: Guide for Urgent are Clinical Team Members (PDF)
• Remittance Inquiry Reference Guide (PDF)
• Somatus is your Resource for Kidney Care Management (PDF)
• Specialty Pharmacy Medical Step Therapy for Hyaluronan Injections (PDF)
• Submitting Prior Authorizations Is Getting Easier (PDF)
• Unspecified Diagnosis Code of Site and Laterality (PDF)
• UPDATED: Blue Cross NC Expands Specialty Pharmacy Precertification List (PDF)

• Abortion (Termination of Pregnancy) (PDF)
• Claims Submission – Required Information for Professional Providers (PDF)
• Claims Timely Filing (PDF)
• Code and Clinical Editing Guidelines (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)
• 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)
• Global Surgical Package (PDF)
• Inpatient Readmissions (PDF)
• Maximum Units Per Day (PDF)
• Modifier 22 (PDF)
• Modifier 24 (PDF)
• Modifiers 25 and 57 (PDF)
• Modifier 63 (PDF)
• Modifier 66 (PDF)
• Modifier 76: Repeat Procedure by the Same Physician (PDF)
• Modifier 91 (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)
• Professional Anesthesia Services (PDF)
• Prosthetic and Orthotic Devices (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)