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Claim Forms

The online form submission is not available to iOS devices (an operating system used for mobile devices manufactured by Apple). If you are using one of these devices please use the PDF to complete your form.

• Claims Inquiry Form (PDF)
• Itemized Bill Submission Form
• Medical/Dental Claim Form (PDF)
• Pharmacy Claim Form (PDF)
• BlueCard Worldwide International Claim Form
• Provider Out of Network Form

Prior Authorization

• Prior Authorization
• Federal Employee Advance Medical Review Forms
• Commercial Prior Authorization List

Utilization Management

• Inpatient Reviews

Little Stars Program Referral

• Little Stars® Physician Referral Form

Appeals

• Blue Card Appeal Request Form
• Member Complaint/Grievance Form
• Member Authorization Form

Provider Services

• Credentialing Application
• MA Waiver of Liability
• Provider Demographic Form

Other Medical Coverage Information

• Other Medical Coverage Information Form

Skilled Nursing Facility Concurrent Review

• Concurrent Review for Post-Acute Form