X14764R07 (02/14) Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
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How to fill out the MN BCBS X14764R07 online
Filling out the MN BCBS X14764R07 form for outpatient therapy authorization requires careful attention to detail. This guide will walk you through each section of the form to ensure accurate and efficient completion.
Follow the steps to complete the MN BCBS X14764R07 form online.
- Press the 'Get Form' button to obtain the form and open it in your editing tool.
- In the Patient Information section, fill in the Member ID, Group number, Member name, Date of birth, Member address, City/state/zip, and Member phone. Ensure all information is accurate and up-to-date.
- Move to the Servicing Provider Information section. Enter the contact person's name, phone number, servicing provider name, servicing provider ID/NPI number, servicing provider address, city/state/zip, servicing provider phone, and servicing provider fax number.
- In the Ordering Provider Information section, confirm if the servicing provider is participating with the local Blue Plan by checking 'Yes' or 'No.' Enter the contact person's name, phone number, ordering provider name, ordering provider ID/NPI number, ordering provider address, city/state/zip, ordering provider phone, and ordering provider fax number.
- Specify the type of therapy requested by selecting from options for Physical Therapy (PT), Occupational Therapy (OT), or Speech Therapy (ST).
- Complete the Services Requested section by providing the date range for the authorization request, the requested number of visits, frequency, primary diagnosis code, diagnosis description, and any secondary diagnosis codes and descriptions.
- Collect and attach the required documentation, including the Initial Evaluation, Specific & Measurable Treatment Goals, and Progress Notes.
- Review the completed form for accuracy, then save your changes. You may choose to download, print, or share the completed form as needed.
Complete your MN BCBS X14764R07 form online today for seamless therapy authorization.
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What is the phone number for BCBS Minnesota Medicare Advantage provider?
(651) 662-5050 or toll free 1-800-262-0823 if you are not eligible for Medicare. (651) 662-9949 or toll free 1-855-579-7658 if you are eligible for Medicare.
Does Blue Cross Blue Shield of Michigan require prior authorization?
BCBSM requires prior authorization for services or procedures that may be experimental, not always medically necessary, or over utilized. Providers must submit clinical documentation in writing explaining why the proposed procedure or service is medically necessary.
What is the payer ID number for BCBS Minnesota?
Claims are processed through Availity using the payer ID code 00562.
Does BCBS Minnesota require prior authorization?
Blue Cross and Blue Shield of Minnesota requires notification/authorization for all inpatient admissions.
Is Anthem the same as Blue Cross Blue Shield Minnesota?
Blue Cross Blue Shield is part of the Anthem family of brands. While the two brands are related, they sell different Medicare plans in different areas.
How do I submit a prior authorization on availity?
How to access and use Availity Authorizations: Log in to Availity. Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations. Select Payer BCBSIL, then choose your organization. Select a Request Type and start request. Review and submit your request.
What is the fax number for prior authorization for BCBS MN?
bluecrossmn.com Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) prior authorization: 866-518-8448; Fax: 1-800-964-3627 To prevent delay in processing your request, please fill out this form in its entirety with all applicable information.
Who is the PBM for BCBS of Minnesota?
Pharmacy Information and Tools Prime Therapeutics is the pharmacy benefits manager for Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) subscribers.
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