Forms and Documents

Provider Quick Reference Guide - Download and print this guide for quick reference to important contact and general information.


Form

Instructions

Fax/Send To:

Prior Authorization

HCAS Standardized Prior Authorization Request Form

General form used for most medical requests. Be sure to attach supporting clinical information.

617-951-3464
(initial requests)

BMCHP Medical Prior Authorization Form

Use this form or the general form for prior authorization requests.

617-951-3464 
(initial requests)

Pharmacy Prior Authorization Forms

Check drug formulary to see if prior authorization is required, then complete the form next to the drug name.

The number on the form; it differs by medication.

Infertility Services Request Form

Prior to submitting, please review the Clinical Coverage Guidelines for Infertility Services to verify that the member meets the Plan's definition of infertile, the eligibility and evaluation requirements, and the coverage criteria for the specific service being requested.

617-951-3464
(initial requests)

Enteral Nutrition Request Form

Choose a BMCHP contracted DME vendor from the attached list.

Fax the completed form directly to the DME vendor.

Claims

Request for Claim Review Form

Multi-purpose; may be used for a variety of administrative appeals, including prior authorization and claims appeals.

BMC HealthNet Plan
Claims
Attn: Provider Appeals
P.O. Box 55282
Boston, MA 02205 

Claims Adjustment and Projects Form

Adjust a submitted claim

Credit Balance Refund Data Sheet

To report overpayments

617-897-0811

Electronic Funds Transfer Form

To set up or update direct pay information

Send to your Provider Relations Consultant

CMS-1500 Claim Form

Submit a claim

CMS-1500 Claim Form

Medicare Part D Vaccine and Administration Claim Form

Submit a claim for a Senior Care Options member

2181 E Aurora Rd
Attn: DMR Department
Suite 201
Twinsburg, OH 44087
dmrrequests@envisionrx.com

Member Support

PCP Selection Form

For members to elect their PCP

617-897-0838

Intensive Clinical Management Release of Information Form

Combined MCE BH Provider PCC Form

Permits the sharing of health information between providers

As listed on forms

Care Management Referral Form (Senior Care Options | All Other Plans)

Refer a member to our Care Management Program

617-951-3426

Coordination of Benefits Indicator (MassHealth | Senior Care Options)

To notify us when a member has other health coverage in addition to BMC HealthNet Plan

617-897-0851

Enrollment and Administrative Forms

Provider Change and Termination Form

For existing providers to change their contact information.

617-897-0818

Member PCP Transfer Request Form

For a provider to complete should they want to modify their patient panel

617-897-0838

Provider Data Form

Submit with complete provider information for credentialing

617-897-0818

Locum Tenens Credentialing Form

To be completed by Locum Tenens providers for credentialing

617-897-0818

HCAS Enrollment Form

Apply to become a BMC HealthNet Provider

617-897-0818

Non-Participating Provider Activation Form

For non-participating providers who will be delivering a one-time service to a member

617-897-0818

Waiver of Liability

For non-participating Senior Care Options providers

617-897-0818

ACOG Form Cover Page

A cover page to accompany ACOG form submissions for our Prenatal Quality Initiative

As listed

Paper Remittance Request Form

Use this form to request paper remittance advices if you are unable to receive electronic remittance advices

617-897-0849


Documents

Document

Purpose

Provider Quick Reference Guide

A useful tool for providers with important contact information.

Pediatric Services at Boston Medical Center

Information on pediatric services and primary care providers at Boston Medical Center.

Prior Authorization

Prior Authorization Matrix

Identifies medical services requiring authorization or notification.

MassHealth
ConnectorCare
Qualified Health Plan

A list of covered services for each plan type.

Appeals

Contract Rate, Payment Policy or Clinical Policy Appeal

An appeal due to a contract rate, payment policy or clinical policy dispute.

Corrected Claims

A previously filed paid or denied claim that you can resubmit with changed or corrected information.

Duplicate Denial Appeal

A request for review of a claim previously processed and denied as duplicate to another claim.

Filing Limit Appeal

An administrative appeal due to a claim denial for filing limit violations.

Prior Authorization Appeal

An administrative appeal due to a claim denial due to lack of prior authorizations for services or for exceeding authorization limits.

Provider Appeals Quick Reference Guide

Assists you in correctly submitting claims appeals.

Request for Additional Information Appeal

Submit in response to a claim originally denied for additional information.

Pharmacy

Mandatory Generic Substitution Program

BMC HealthNet Plan will authorize coverage of prescriptions where the prescriber has written "No Substitution" when appropriate criteria are met.

Medical Exception Process

The Medication Exception Process gives a member or the member's authorized representative the ability to request coverage of a non-covered medication based upon medical necessity.

New-to-Market Medication Program

Criteria for prior authorization coverage of new-to-market medications or new indication(s).

Over the Counter Formulary

Lists the accepted generic versions of approved over-the-counter drugs.

Quantity Limitation Guide

Dose and strength recommendations for drugs.

Specialty Drug List

List of special pharmacies, drugs, categories, and codes.

Prescription Drug Monitoring Program

Helps to identify member at risk of inappropriate drug use.