Behavioral Health
Form Name and Description | Revision Date |
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Applied Behavior Analysis (ABA) Initial Treatment Request forms: |
Updated 1/1/2019 |
Behavioral Health Discharge Clinic Form | Added 10/2022 |
Coordination of Care | Added 04/2015 |
Electroconvulsive Therapy (ECT) Request Form | Updated 8/14/2023 |
Intensive Outpatient Program (IOP) Request Form | Updated 8/14/2023 |
Psychological or Neuropsychological Testing Request Form | Updated 3/16/2023 |
Repetitive Transcranial Magnetic Stimulation | Updated 09/2015 |
Therapeutic Behavioral On-Site Services Request Form | Updated 04/14/2023 |
Transitional Care Request | 12/20/2020 |
Claims
Form Name and Description | Revision Date | |
---|---|---|
AI/AN Limited Cost-Sharing Referral Form | 05/01/2020 | |
Claim Review Form OK Contracted Provider Claim review Form |
Updated 02/06/2023 | |
Corrected Claim Form OK Corrected Provider Claim Form |
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Additional Information Form OK Additional Information Form |
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Appeal Request Form | ||
Expedited Pre-service Clinical Appeal Request Form (Commercial networks only) | 03/07/2022 | |
Attending dentist's statement Complete and mail to assure timely payment of submitted claims. |
Updated 03/30/2006 | |
CMS-1500 User Guide This guide will help providers complete the CMS-1500 (08/05) form for patients with Blue Cross and Shield of Oklahoma insurance. |
Updated 07/17/2014 | |
Coordination of Benefits Questionnaire | Updated 03/01/2008 | |
Check and Voucher Request |
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Provider Refund | Updated 09/11/2020 |
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UB-04 User Guide This guide will help providers complete the UB-04 form for patients with Blue Cross (facility) coverage. |
Electronic Commerce
Form Name and Description | Revision Date |
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Enroll online for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) via Availity® – learn more! | 5/3/2021 |
Medical Management
Form Name and Description | Revision Date | |||||||||||||||
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BlueLincs HMO Allergy Authorization Request | Added 04/27/2009 | |||||||||||||||
BlueLincs HMO Referral / Authorization Request Information that BlueLincs needs for referrals and authorizations. |
Updated 07/22/2014 | |||||||||||||||
Botulinum Toxin Form | Added 06/18/2013 | |||||||||||||||
Genetic Testing Form | Added 03/04/2014 | |||||||||||||||
Hyperbaric Oxygen Pressurization | Added 03/26/2010 | |||||||||||||||
Immunoglobulin Therapy Request | Updated 06/30/2008 | |||||||||||||||
Recommended Clinical Review (Predetermination) Request | Updated 06/21/2023 | |||||||||||||||
Wheelchair Medical Necessity and Home Evaluation Verification
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