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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.

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

Subscriber Claim Form

Medical benefits subscriber claim form.

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How to submit a claim: 

Download and complete the claim form, then you have the option to mail in or submit online.

To submit online, sign into your member account and upload the form.

Pharmacy (Part D)

Medicare Part-D Prescription Claims Form

Complete this Medicare Part D Prescription Drug Claim Form to request reimbursement for Medicare Part D prescription drug benefits if you did not receive coverage at a pharmacy.

Drug Mail Order Form

Complete this form to request Home Delivery through Express Scripts

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.


Out-of-Network Vision Services Claim Form

Complete this form if you are visiting a provider that is not a participating provider in the EyeMed network. For vision reimbursement claims through 12/31/20 please submit to EyeMed.

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 Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. 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: March 6, 2021