| Forms for Providers |
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. Electronic Funds Transfer Application [PDF] Admissions and Recertifications Form [PDF] Continuity of Care Request Form [PDF] Coordination of Benefits Questionnaire Health Delivery Organization (HDO) Information Form [PDF] Louisiana Standardized Credentialing Form Network Interest Form Overpayment Notification Form Pharmacy Request Form [PDF] Provider Update Form Reimbursement Review Form [PDF] Release of Protected Health Information Form [PDF] Get help opening PDF files.
To 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 [PDF].
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 [PDF]
Key Dentists should attach this form to the dental claim form when a member chooses an alternative, non-covered treatment.
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.
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.
This form and the subsequent attachments (A–D) are used in the credentialing process. For more information and instructions on this process, visit the facility credentialing page.
This form is posted on the Louisiana Department of Insurance website.
Complete this form to receive information about becoming a member of a BCBSLA provider network.
Complete this form to notify us of a possible overpayment for an out-of-state member's claim.
Pharmacy 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 877.776.8735.
Use this form to provide BCBSLA with new information on your practice.
If you disagree with the way a claim was processed, you may submit this form along with the original claim and supporting documentation.
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.