Below are some of our commonly used provider forms. Our forms are updated regularly. Please use the most current form to avoid delays in processing. Read each form carefully for special instructions and/or submission information. All forms are readable in Adobe Acrobat Reader [PDF] format and can be printed using your computer.
Admissions and Recertifications Form Use this form for admissions and recertifications for rehabilitation centers (rehab), skilled nursing (SNF) and long term acute care (LTAC) services.Alternative Dental Procedure Payment Responsibility Form Key Dentists should attach this form to the dental claim form when a member chooses an alternative, non-covered treatment.
Use this form to submit authorizations for Blue Cross and HMOLA members for inpatient, outpatient and offices services handled directly by our authorization department. This form should not be used for authorizations processed by AIM, Express Scripts or Magellan, etc.
Behavioral Health Provider Clinical Profile Form
Behavioral Health providers should complete this form to disclose the most current information regarding their areas of expertise. This form is used in our credentialing and recredentialing processes. Failure to complete this form could delay your credentialing/recredentialing application.
Continuity of Care Request Form
Doctors who leave our networks while treating a member for certain conditions can work with their patient to request a continuation of direct payment from BCBSLA/HMOLA at a higher network level of reimbursement for a limited time. This form must be completed by the provider and member and submitted to BCBSLA/HMOLA within 30 days of network termination.
Coordination of Benefits Questionnaire
This form is available to providers servicing out-of-area or BlueCard® members who are covered by two or more medical or dental insurance plans.
Electronic Funds Transfer ApplicationTo sign up for our free EFT service, complete this application and submit it along with a voided check. For more information on EFT options, view the the Electronic Funds Transfer FAQs.
Electronic Funds Transfer Termination or Change FormTo stop receiving your Blue Cross and Blue Shield of Louisiana (BCBSLA) payments via electronic funds transfer (EFT) or to change your EFT information, please use this form.
External Review of Billing Disputes Effective November 21, after physicians or physician groups have exhausted our internal dispute resolution processes under the provider contract, they may submit a billing dispute through MES Solutions, an independent company contracted by us to act as an external billing dispute reviewer. This process is only available to physicians and physician groups, and applies only to disputes regarding the application of coding and payment rules and methodologies. The decision of the external reviewer is binding on both the health plan and the physician.
Facility Reporting Form
Complete this form in accordance with the Louisiana Consumer Health Care Provider Network Disclosure Law to report all hospital-based anesthesia, emergency room, neonatology, radiology and pathology providers.
Health Delivery Organization (HDO) Information Form
This form and the subsequent attachments (A-E) are used in the credentialing process. For more information and instructions on this process, visit the facility credentialing page.
Louisiana Standardized Credentialing Form This form is posted on the Louisiana Department of Insurance website.
Network Interest FormComplete this form to receive information about becoming a member of a BCBSLA provider network.
Overpayment Notification FormComplete this form to notify us of a possible overpayment for an out-of-state member's claim.
Pharmacy Request FormPharmacy providers not participating with Express Scripts, Inc. (ESI) should complete this form to provide BCBSLA with your most current information. If you are unsure of your ESI participation, call 1.877.776.8735.
Provider Update Form Use this form to provide BCBSLA with new information on your practice.
Reimbursement Review Form If you disagree with the way a claim was processed, you may submit this form along with the original claim and supporting documentation.
Release of Protected Health Information Form This form is used for individuals to authorize a health care provider or other entity to disclose protected health information to Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc. for the purpose stated.
Request for Taxpayer Identification Number and Certification
Download this form from the Internal Revenue Service.
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