Get Request For Out-of-network Benefits - Bcbst.com

This guide provides clear and concise instructions to assist users in filling out the Request For Out-of-Network Benefits form online. By following these steps, you will ensure that you provide all the necessary information for a successful request.

Follow the steps to complete the form smoothly.

1. Press the ‘Get Form’ button to access the Request For Out-of-Network Benefits form and open it in the document editor.
2. Fill in the required fields at the top of the form, including the referral number, member name, member ID, and date of birth.
3. Enter the primary care practitioner (PCP) details, including their name, provider ID or NPI number, specialty, telephone number, and fax number.
4. Provide the information for the non-participating practitioner or facility. This includes the name, provider ID or NPI number, tax ID number, specialty, telephone number, fax number, and complete address.
5. If applicable, include the hospital name for outpatient, 23-hour, or inpatient services, along with its address.
6. Document the member’s medical information by attaching any related records necessary for the services to be rendered. Specify symptoms/diagnoses using the appropriate ICD-9 codes and outline the services or procedures to be provided with relevant CDT, CPT, or HCPCS codes.
7. Indicate the frequency and duration of the requested services, stating specifics such as '2 times per week for 6 weeks' as needed.
8. Clearly state the reasons why services cannot be provided by an in-network facility or practitioner, addressing particular needs like sub-specialist access or continuity of care.
9. Review all filled information for accuracy, ensuring no detail is overlooked as all information is necessary for prior authorization.
10. Once completed, save the changes made to the form. You may also download, print, or share the document according to your needs.

Complete your Request For Out-of-Network Benefits online today to ensure all necessary services can be accessed.