Miscellaneous Forms
Last Updated: Wednesday, March 04, 2026
On this page, you will find some recommended forms that providers may use when communicating with Highmark, its members or other providers in the network.
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- Affirmation of Medical Practice Statement
- Bone Density Information Form
- General Certificate of Medical Necessity
- Provider Post Service Appeal Form
- PWK (Paperwork) Supplemental Claim Information Cover Sheet
- Request for IVF Coverage
- Request for IVF Coverage State of Delaware Employee Plan Members Only
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Quality Compliance Forms
- Breast Cancer Screening (BCS)
- Cervical Cancer Screening (CCS)
- Childhood Immunizations (CIS)
- Colorectal Cancer Screening (COL)
- Immunizations for Adolescents (IMA)
- Osteoporosis Management in Women (OMW)
- Hemoglobin A1c for Patients with Diabetes (HBD)
- Eye Exam for Patients with Diabetes (EED)
- Statins Therapy for Patients with Cardiovascular Disease (SPC)
- Kidney Health Evaluation for Patients with Diabetes (KED)
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Quality Compliance Forms
- Breast Cancer Screening (BCS)
- Cervical Cancer Screening (CCS)
- Childhood Immunizations (CIS)
- Colorectal Cancer Screening (COL)
- Immunizations for Adolescents (IMA)
- Osteoporosis Management in Women (OMW)
- Hemoglobin A1c for Patients with Diabetes (HBD)
- Eye Exam for Patients with Diabetes (EED)
- Statins Therapy for Patients with Cardiovascular Disease (SPC)
- Kidney Health Evaluation for Patients with Diabetes (KED)
Appeals Forms
- Provider BlueCard Claim Appeal Form - This form can be used to initiate a provider appeal of a BlueCard claim.
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- Designation of Authorized Representative Form
- Designation of Authorized Representative - Managed Care (HMO) Complaints
- Designation of Authorized Representative Form - Medicare Advantage
- Physician Certification for Expedited Review Form
- Request for Independent External Review of an Adverse Benefit Determination
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Miscellaneous Forms
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Miscellaneous Forms
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Notice of Medicare Non-Coverage (Freedom Blue PPO Members, Medicare Advantage)
Here you will find the Notice of Medicare Non-Coverage (NOMNC) form that skilled nursing facilities, home health agencies, and CORFs must deliver to Medicare Advantage patients no later than two days before services will end.
The completed NOMNC form can be uploaded in Predictal or faxed to 888-740-4318.
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Notice Of Medicare Non-Coverage (NOMNC)
The completed NOMNC form can be uploaded in Predictal or faxed to 888-740-4318.
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Notice Of Medicare Non-Coverage (Freedom Blue PPO Members)
The completed NOMNC form can be uploaded in Predictal or faxed to 888-740-4318.
Detailed Notice of Discharge (DENC)
Updated Instructions
Effective Jan. 1, 2025, the Centers for Medicare and Medicaid Services (CMS) released special instructions for repeat appeals within the same episode of care:
- If the enrollee has previously received a favorable Quality Improvement Organization (QIO) appeal decision during the current episode of care, detail the specific change(s) in the enrollee’s condition since the previous appeal that provides the basis for this decision to terminate services.
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Detailed Notice of Discharge (Freedom Blue PPO Members)
The completed DENC form can be uploaded in Predictal or faxed to 888-740-4318.
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Detailed Notice of Discharge (Medicare Advantage Members)
- Detailed Notice of Discharge - Community Blue Medicare HMO
- Detailed Notice of Discharge - Freedom Blue PPO Members
- Detailed Notice of Discharge - Security Blue PPO Members
Completed DENC forms can be uploaded in Predictal or faxed to 888-740-4318.
