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 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.

• Abortion (Termination of Pregnancy) (PDF)
• Claims Submission - Required Information for Facilities (PDF)
• Claims Submission – Required Information for Professional Providers (PDF)
• Claims Timely Filing (PDF)
• Code and Clinical Editing Guidelines (PDF)
• Consultations (PDF)
• Corrected Claims (PDF)
• Diagnosis-Related Group (DRG) Inpatient Facility Transfers (PDF)
• Diagnosis Used in DRG Computation (PDF)
• Drug Screen Testing (PDF)
• Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) (PDF)
• Duplicate or Subsequent Services on the Same Date of Service (PDF)
• Durable Medical Equipment (DME) (Rent to Publish) (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)
• Hysterectomy (PDF)
• Inpatient Readmissions (PDF)
• Maternity Services (PDF)
• Maximum Units Per Day (PDF)
• Medical Recalls (PDF)
• Modifier 22 (PDF)
• Modifier 24 (PDF)
• Modifiers 25 and 57 (PDF)
• Modifiers 26 and TC (PDF)
• Modifiers 50 and 51 (PDF)
• Modifier 63 (PDF)
• Modifier 66 (PDF)
• Modifier 76: Repeat Procedure by the Same Physician (PDF)
• Modifier 77 (PDF)
• Modifier 78 (PDF)
• Modifiers 80, 81, 82, and AS: Assistant at Surgery (PDF)
• Modifier 90 (PDF)
• Modifier 91 (PDF)
• Modifiers LT and RT (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)
• Portable/Mobile/Handheld Radiology Services (PDF)
• Preadmission Services for Inpatient Stays (PDF)
• Preventive Medicine and Sick Visits on the Same Day (PDF)
• Professional Anesthesia Services (PDF)
• Proof of Timely Filing (PDF)
• Prosthetic and Orthotic Devices (PDF)
• Provider Preventable Conditions (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)
• Transportation Services: Ambulance and Nonemergent Transport (PDF)