Below are links to various utilization-management-related forms, some of which are used to request authorization for various services. These forms are also available, along with others, on BCN's Forms page within Provider Secured Services. To access the complete Forms Library, log in to Provider Secured Services, click BCN Provider Publications and Resources and then click Forms.
Skilled nursing facilities and home health agencies
Hospitals, for patients in observation
Hospitals, for inpatients
- Waiver of Liability (PDF)
- Patient Assessment Form (PDF)
Behavioral health services
Drugs covered under the medical benefit
For information about drugs covered under the medical benefit, visit the Medical Benefit Drugs – Pharmacy page on this website.
Transitional care services
- LTACH Assessment Form (PDF) – for BCN HMO members admitted anytime and for BCN Advantage members admitted through May 31, 2019
- Rehabilitation Assessment Form (PDF) – for faxing rehabilitation and SNF requests BCN HMO members admitted anytime and for BCN Advantage members admitted through May 31, 2019
- Skilled nursing facility assessment form (PDF) – for attaching to the case in the e-referral system starting Dec. 1, 2020, for Blue Care Network commercial members
Note: For BCN Advantage members admitted to post-acute care on or after June 1, 2019, see Post-acute care services: Frequently asked questions by providers (PDF).