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Administrative Forms

Coverage Determination Form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.

Drug Claim Form
Coordination of benefits / Direct claim form.

Drug Mail Order Form
Express Scripts order form.

Health Care Proxy Form
Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent and to make health care decisions for you if you lose the ability to make decisions for yourself.

Medicare Advantage Request for Appeal
For use when appealing the denial of a service or claim. Appeal requests must be made within 60 calendar days of the denial notification.

Request for Redetermination Part D Prescription Drug Denial
If BlueShield of Northeastern New York denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Dental Reimbursement Form
Medicare Advantage dental receipt reimbursement form — complete and submit for reimbursement.

EyeMed Out-of-Network Vision Services Claim Form

Subscriber Claim Form
Medical benefits subscriber claim form.

Medicare Questions?

We're here to help.

1-833-735-4512 (TTY 711)
Oct. 1 - Dec. 31, 8 a.m. - 8 p.m., 7 days a week
Jan. 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday

BlueShield of Northeastern New York (BSNENY) is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711)

Content last updated October 15, 2019.