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Provider Supply Forms
Blue Care Network Providers
BCN forms are available on the Forms page in BCN Provider Publications and Resources on web-DENIS. Form categories include:
- Medical Exam
- Member Materials
- Member Benefits
- Care Management
- Disease Management
- Pharmacy
- Behavioral Health
- Claims
- BCN Advantage
- BlueCaid
Links to BCN forms are also available in the Forms chapter of the BCN Provider Manual, located in BCN Provider Publications and Resources on web-DENIS.
The Status Claim Review Form, used to request a claim review, submit corrections or submit missing information, is available both on the Forms page on web-DENIS and the Forms chapter of the BCN Provider Manual.
Dental Providers
Blue Cross Blue Shield of Michigan accepts claims on the 2006 and 2002, 2004 American Dental Association form. Call the ADA at 1-800-947-4746 to order the form.
BCBSM offers a self-addressed envelope, Form No. 2685, for returning dental claim forms. Use the Facility and Professional Provider Supply Requisition Form (PDF) to order a supply. Complete the form and mail or fax it to us using the contact information provided.
Vision & Hearing Providers
Blue Cross Blue Shield of Michigan will provide many of the supplies you need to prepare and submit vision claims. The items listed below are some of the supplies that you can order using the Facility and Professional Provider Supply Requisition Form (PDF). Complete the form and mail or fax to us using the contact information provided.
- No Cost Items
- BCBSM self-addressed envelopes for returning claim forms (CS 5129)
- Michigan health benefits claim review (CC 6742)
- For Sale Items
- CMS-1500 two-ply continuous feed claim form ($40.67/1,000 forms)
- CMS-1500 two-ply snap out claim form ($20.88/500 forms)
- CMS-1500 one-ply continuous feed claim form ($15.61/1,000 forms)
