- The Healthy Blue Network
- Prior Authorization & Claims
- Eligibility & Benefits
- Provider Support
Forms
Pharmacy
Precertification
Claims & Billing
Behavioral Health
- BH Interactive Care Reviewer Training Presentation
- Behavioral Health Non-licensed Practitioners
- Substance Abuse Level of Care Tool
- Comprehensive Diagnostic Evaluation Form
- Applied Behavioral Analysis (ABA) - Plan of Care
- Applied Behavior Analysis — Authorization Request
- Psychological Testing Request Form
- Initial Review Form
- Outpatient Treatment Request Form
- Concurrent Review Form
- Certification of Need for Psych Hospital
- Neuropsych Testing Form
- Psychiatric Residential Treatment Facilities Initial Review Form
- Discharge Note Fax Form
Other Forms
- Practice Profile Update Form
- MCS Notification of Delivery Form
- Independent Review Provider Reconsideration Form
- Case Management Referral Form
- Reconsideration and Appeal Representative Form
- New Patient Acceptance Form
- LDH Adverse Incident Reporting Form
- Provider Complaint Form
- Authorization to Release or Obtain Health Information
- Nonemergent Transportation Request Form
- PCP Reassignment Request Form
- Certification of Ambulance Transportation
