Administrative
Appeals
| File Name | Line(s) of Business | Format |
|---|---|---|
| Non-Contracted Medicare Advantage Appeal Form | Medicare | |
| Provider Clinical Appeal Instructions and Form | all lines of business | |
| Provider Reconsideration/Administrative Appeal Instructions Form | all lines of business |
Authorizations & Referrals
| File Name | Line(s) of Business | Format |
|---|---|---|
|
Protocol Exemption Form for Procedures, Treatment and Medications |
Commercial | Florida Blue site |
| Medicare Part B Drug Prior Authorization Request Form | Medicare | |
| Medicare Part B Drug Prior Authorization Request Form - Continuous Glucose Monitor (CGM) | Medicare |
Claims & Billing
| File Name | Line(s) of Business | Format |
|---|---|---|
| Billing Authorization for Provider Groups | all lines of business | external site |
| Claim Overpayment Refund Form | all lines of business | |
| Independent Dispute Resolution Process: Open Negotiation Notice and Form | Commercial, Federal Employee Program | |
| BCBCA Coordination of Benefits Questionnaire | BlueCard |
Coordination of Patient Care
| File Name | Line(s) of Business | Format |
|---|---|---|
| Care Management Referral Form | Commercial, FEP | |
| Clinical Care Programs Referral Form (for Complex or Chronic Health Conditions) | all lines of business | |
| Medicare Clinical Care Programs Referral Form | Medicare | |
| Medicare Continuity of Care Form | Medicare |
Pharmacy
| File Name | Line(s) of Business | Format |
|---|---|---|
| Accredo Prescription Enrollment Form | Commercial, Medicare | |
| Contraceptive Tier Exception Request Instructions | Commercial | FB site |
| CoverMyMeds | all lines of business | external site |
| CVS Caremark Hemophilia Enrollment Form | all lines of business | |
| CVS Caremark Specialty Pharmacy Enrollment Form | all lines of business | |
| Dispense As Written (DAW) Penalty Waiver Request Form | Commercial | |
| HIV PrEP Tier Exception Form | Commercial | |
| Skilled Nursing Facility Select Medication Program Order Form | all lines of business |
Quality Care
| File Name | Line(s) of Business | Format |
|---|---|---|
| Adult Summary of Conditions, Procedures, and Preventive Care Form | Commercial, FEP, Medicare | |
| Pediatric/Adolescent Summary of Conditions, Procedures, and Preventive Care | Commercial, FEP | |
| Preservice Fax Cover Sheet for Medical Records | all lines of business |
Member Forms
Florida Blue members can access a variety of forms including: medical claims, vision claims and reimbursement forms, prescription drug forms, coverage and premium payment and personal information.
Medicare Plans
Forms for Florida Blue Medicare members enrolled in BlueMedicare plans (Part C and Part D) and Medicare Supplement plans.
Individual, Family & Employer Plans (non-Medicare)
Forms for Florida Blue members enrolled in individual, family and employer plans.