Approvals and denials are based on approved Medical Policies. This request is for verification of benefits, prior to rendering services, that may be considered experimental, investigational, or cosmetic. This request is for a clinical review if the Intensive Outpatient Program treatment meets the medical necessity definition under the member's health benefit plan.
Intensive Outpatient Program (IOP) Request This request is for a clinical review if Electroconvulsive Therapy meets the medical necessity definition under the member's benefit health plan. This form is available as an option but providers may use their own Coordination of Care Form if they choose. This request is to provide member treatment information to another treating provider or request member treatment information from another treating provider. If a member has been selected to be a part of the Focused Outpatient Management Program, this form is to be completed by the outpatient therapist or prescribing provider.
This form is to be used after the initial form and initial visit have been completed. This request will need to be completed for ongoing ABA sessions along with the Member Treatment Schedule. This request will need to be completed for the first Applied Behavior Analysis (ABA) session along with the Member Treatment Schedule.Īpplied Behavior Analysis (ABA) Initial Assessment Request Form Standard Authorization to Use or Disclose Protected Health Information (PHI)Ĭomplete and submit this form to allow the disclosure of your Personal Health Information (PHI) to any specific person or entity.Īpplied Behavior Analysis (ABA) Clinical Service Request Form Use this claim form to request reimbursement for applicable prescription drug expenses incurred for services not directly billed to the plan. Use this Blue Cross Blue Shield Global Core International Medical Claim form to request reimbursement for applicable medical expenses incurred internationally for services not directly billed to the plan.
Use this claim form to request reimbursement for applicable medical expenses incurred for services not directly billed to the plan. Please be sure to complete the Disabled Dependent Form in its entirety, including the accompanying Physician Certification section on the second page. To help ensure benefits are administered in accordance with your Boeing health care benefit plan, your plan requires annual recertification. Use this form to certify disabled dependent status. To determine if Coordination of Benefits is available and appropriate, Blue Cross and Blue Shield of Illinois may ask you to complete the Coordination of Benefits Questionnaire.
If you or your dependents are covered under more than one medical plan, the plans will work together to coordinate the benefits you receive.
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