Formularios
To make it easier to find the forms you use regularly, we’ve put them all in one place. Some forms can be submitted online, and others can be printed and then faxed or mailed to us. (There are specific instructions on each form.)
Claims & Billing
Claims Adjustment Request
CMS-1500 (02-12) Form Completion Informational Guide
Coordination of Benefits Questionnaire
Direct Deposit Agreement
Modifier 22 Unusual Procedural Services
Observation Level of Care Timely Filing Appeal Special Handling Form
Offshore Subcontracting Questionnaire
Provider Appeal Request Form
Skilled Nursing Facility Wound Vac Reimbursement Request Submission Cover Sheet
SNF RX Reimbursement Request Form
UB-04 Form Completion Informational Guide
Unlisted Code Claim Form for Durable Medical Equipment and Orthotics & Prosthetics Providers
Unlisted Procedure Claim Form for Facilities
Unlisted Procedure Claim Form for Physicians
W-9
Coordination of Patient Care
Alzheimer Association Referral Form
Authorization Fax Request Form
BCBSRI Medicare Advantage Non-Skilled Home Health Care Benefit – FAQ
Behavioral Health Authorization Request Form (Non Portal Users)
Care Coordination Referral Form
FEP Consent for Case Management Form
Infertility Treatment Form
Instructions for Completing the Oral Enteral Food Products Reimbursement Form
Oral Enteral Food Products Reimbursement Form
Out of Network Request Form
Preauthorization Form for Oral Enteral Nutrition
SNF Request Form For PCP Offices
Provider Access/Administration
Email Address Update Form
Hospital Privileges
Medical Records Cover Sheet
Medicare opt out form
Policy Request Form
Practitioner Change Form
Primary Care Physician Selection Form
Primary Care/Behavioral Health Communication Form
Request for Change Of Participating Status For BlueCHiP for Medicare
State of Rhode Island Interpreter Form
Voluntary Termination
HIPAA Transactions
270-271 Companion Guide
270-271 How To Conduct Partner Testing
276-277 Companion Guide
276-277 How To Conduct Partner Testing Instructions
277CA Health Care Claim Acknowledgement Companion Guide
278 HIPAA 5010 Health Care Services Review Request for Review and Response Companion Guide
278 How To Conduct Partner Testing
820 Companion Guide
820 How To Conduct Partner Testing
834 Companion Guide
834 How To Conduct Partner Testing
835 HIPAA 5010 Health Care Claim Payment/Advice Companion Guide
837 and 835 How To Conduct Partner Testing
837 HIPAA 5010 Health Care Claim: Dental Companion Guide
837 HIPAA 5010 Health Care Claim: Institutional Companion Guide
837 HIPAA 5010 Health Care Claim: Professional Companion Guide
BCBSRI 27x Real-Time API
BCBSRI Blue Gateway - HTTPS Connection & Transmission Procedures
BCBSRI Blue Gateway - SFTP Connection & Transmission Procedures
Data Transfer Worksheet
Provider Control Report Error Message Code Guide
Trading Partner Agreement
Trading Partner Registration Form