Applied Behavior Analysis (ABA) Initial Treatment Request forms:
| Form Name and Description | Revision Date |
|---|---|
| AI/AN Limited Cost-Sharing Referral Form | 08/29/2024 |
| Claim Review Form OK Contracted Provider Claim review Form | Updated 12/21/2023 |
| Corrected Claim Form OK Corrected Provider Claim Form | Updated 11/21/2023 |
| Additional Information Form OK Additional Information Form | Updated 11/21/2023 |
| Expedited Pre-service Clinical Appeal Request Form (Commercial networks only) | 03/07/2022 |
| Dental Claim Form Complete and mail to assure timely payment of submitted claims. | Updated 12/2023 |
| CMS-1500 User Guide This guide will help providers complete the CMS-1500 (Version 02/12) form for patients with Blue Cross and Shield of Oklahoma insurance. | Updated 12/20/2023 |
| Coordination of Benefits Questionnaire | Updated 03/01/2008 |
| Check and Voucher Request | Updated 02/12/2024 |
| Provider Refund | Updated 09/11/2020 |
| Form Name and Description | Revision Date |
|---|---|
| Enroll online for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) via Availity ® – learn more! | 5/3/2021 |
| Form Name and Description | Revision Date |
|---|---|
| BlueLincs HMO Referral / Authorization Request Information that BlueLincs needs for referrals and authorizations. | Updated 02/26/2024 |
| MyBlue HMO PCP Referral | Updated 03/07/2024 |
| Recommended Clinical Review (Predetermination) Request | Updated 11/21/2023 |
| Wheelchair Medical Necessity and Home Evaluation Verification |
| Form Name and Description | Revision Date |
|---|---|
| Standard Authorization Form and other HIPAA Privacy Forms Authorizes Blue Cross and Blue Shield of Oklahoma to disclose protected health information only to those individuals specified by the member. Protected health information is defined by privacy rules enacted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. |
For more information on how to join our networks and additional documentation requirements, please visit the Network Participation section.
Mail Order: ePrescribe new prescriptions to EXPRESS SCRIPTS HOME DELIVERY or
call 888-327-9791 for faxing instructions.
Affordable Care Act (ACA) Copay Waiver Form and Program Summary to request $0 member cost share for preventive drug products not covered on a BCBSOK commercial plan drug list
Formulary Coverage Exception form to request coverage for drug products not covered on a BCBSOK commercial plan drug list
| Form Name and Description | Revision Date |
|---|---|
| Medicare Advantage Annual Wellness Visit Form | Added 06/05/2020 |
| Form Name and Description | Revision Date |
|---|---|
| Asthma Action Plan Template | Updated 01/18/2013 |
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