Mountain State BCBS - Provider Forms

To view our documents, you need the Adobe Reader. We recommend version 6.0 or higher for your computer. To get a FREE version of Adobe's software, along with website access to Adobe's Installation Instructions and Technical Troubleshooting Guide, just click on the "Get Adode Reader" button.

MSBCBS Professional Forms

		Announcement of Provider Reimbursement/Change Form
		Provider Reimbursement/Change Form
		Provider Inquiry
		Specialty Drug Request Form - effective January 6, 2006
		(Click here for more information about the Specialty Drug Program)
		Special Bulletin - Attention Providers Receiving Electronic Funds Transfer Notices (EFT)
		Provider Electronic Fund Transfer Form

MSBCBS Professional Electronic Forms
		National Standard Format Version 2.0 - includes all updates
		Updates: DA0 Primary (Source of Payment - updated 3/2/01
		Updates: BA1 (12&18), DA0 Primary (10), DA0 Secondary (5) FA0 (49), XA0 (20) - updated 2/16/01
		NSF Claim Edits And Rejection Reasons

MSBCBS Facility Electronic Forms
		UB-92 Version 5.0 Flat File Format - includes all updates
		Updates: RT 30 (Source of Payment) - updated 3/2/01
		UB-92 Claim Edits and Rejection Reasons

MSBCBS Miscellaneous Forms
		MSBCBS Privacy Form Standard Authorization
		Claim Attachment Fax Cover Sheet
		MHSA Treatment Plan Authorization Request
		Notice of Medicare Non-Coverage
		(Click here for more information about the "Notice of Discharge & Medicare Appeal Rights" and "Notice of Medicare Non-Coverage")
		Therapy Treatment Plan Form
		OPL/COB Questionnaire
		Medical Policy Inquiry Form