BCN Care Management Forms

Care Management Forms

Below are links to various care-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 web-DENIS Forms page. To access the complete Forms Library, log in to Provider Secured Services, click BCN Provider Publications and Resources and then click Forms.

Bariatric surgery

BCN Advantage^SM

Skilled nursing facilities and home health agencies

Medicare regulations (PDF) (See sections 90.2 through 90.5)
Notice of Medicare Non-Coverage (DOC)
Notice of Medicare Non-Coverage (PDF)
NOMNC form instructions (PDF)
Detailed Explanation of Non-Coverage (DOC)
Detailed Explanation of Non-Coverage (PDF)
DENC form instructions (PDF)

Hospitals, for patients in observation

Medicare Outpatient Observation Notice (PDF)
MOON form instructions (PDF)

Noncontracted providers

Waiver of Liability (PDF)

Member form

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.

e-referral

Sign up or change a user

Transitional care services

Home Care Form (PDF)
LTACH Assessment Form (PDF)
Enteral and TPN Nutrition Assessment / Follow-up Form (PDF) - for home infusion providers only
Rehabilitation Assessment Form (PDF)