Miscellaneous Forms

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• cpa/ sepa

• Assignment of Major Medical Claim Form
• Authorization for Behavioral Health Providers to Release Medical Information
• Expanded Provider Directory - Group
• Expanded Provider Directory - Practitioner
• PWK (Paperwork) Supplemental Claim Information Cover Sheet
• Waiver of Liability Statement

• cpa/ sepa

• Guide to Sexual History Taking
• Return of Monies

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• Care Transition Care Plan
• Request for Drug Coverage from Pharmaceutical Management Program
• Return of Monies

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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
• Inpatient Rehabilitation (Initial or Continued Stay) Worksheet (Medicare Advantage)
• Request for IVF Coverage
• Request for IVF Coverage State of Delaware Employee Plan Members Only
• Skilled Nursing Facility Continued Stay Worksheet (Medicare Advantage)
• Skilled Nursing Facility Precertification (Initial) Worksheet (Medicare Advantage)

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• cpa/ sepa
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• wv

• Long-Term Acute Care Facility (Initial or Continued Stay) Worksheet (Commercial or Medicare Advantage)
  
• Inpatient Rehabilitation (Initial or Continued Stay) Worksheet (Commercial)
• Skilled Nursing Facility Continued Stay Worksheet  (Commercial)
• Skilled Nursing Facility Precertification (Initial) Worksheet  (Commercial)
  

• wpa/ nepa
• cpa/ sepa
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• Patient Treatment Summary Communication Form

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• Checklist for Issuing a Notice of Medicare Non-Coverage (NOMNC)
• Electronic Claim Attachment Cover Sheet
• Highmark West Virginia Privacy Form Standard Authorization

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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)

• cpa/ sepa
• de
• wpa/ nepa
• wv

Appeals Forms

• wpa/ nepa
• cpa/ sepa

• 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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• Designation of Personal Representative for Appeal Processes

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Miscellaneous Forms

• Claim Inquiry Form
• PWK (Paperwork) Supplemental Claim Information Cover Sheet

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Miscellaneous Forms

• Claim Inquiry Form
• PWK (Paperwork) Supplemental Claim Information Cover Sheet

• wv

• Designation of Authorized Representative Form

• wpa/ nepa
• cpa/ sepa

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.

• NOMNC for Freedom Blue PPO Members

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• wny
• neny

Notice Of Medicare Non-Coverage (NOMNC)

• Notice of Medicare Non-Coverage

• wv

Notice Of Medicare Non-Coverage (Freedom Blue PPO Members)

• Notice of Medicare Non-Coverage for Freedom Blue PPO Members

• cpa/ sepa
• wv

Detailed Notice of Discharge (Freedom Blue PPO Members)

• Detailed Notice of Discharge - Freedom Blue PPO Members

• wpa/ nepa

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