Enrollment Form Tutorial
Helping patients enroll for support programs can present unique challenges. Watch this video and learn about the enrollment process for BMS Access Support.
This video is intended for HCPs.
Forms and resources for you and your patients
Below is a library of resources, including CMS forms, checklists, and appeal template letters. Educational guides are also available to help your patient navigate the insurance coverage process and understand how BMS can support them throughout their treatment journey.
Most Requested Downloads
Enrollment forms, coding and reimbursement guides, and an introduction to getting started with BMS Access Support®.
*Template letters are provided as examples of potential correspondence.
Claim Documents
Standard claim form for physician office.
Standard claim form for hospital outpatient.
Annual Reverification
Reverification Guide
This guide will provide you with information regarding the BMS Patient Support annual reverification process.
Reverification Template
Template to assist your office and streamline Annual Reverification of benefits for your patients.
Office Support Tools
Formulary Exception Template Letter*
Template letter to request a formulary exception.
Patient Benefits Information Form
Benefits and coverage summary form for patients.
Medically Unlikely Edit (MUE) Appeal Template Letter*
This template is offered as a resource to use when writing to appeal the Medically Unlikely Edit (MUE) that is in place for a certain drug and to provide documentation of the medical necessity of that drug.
Medical Necessity Template Letter*
Template letter to document the medical necessity of a drug.
REBLOZYL® Medical Necessity Template Letter*
Template letter to document the medical necessity of REBLOZYL.
Prior Authorization Denial/Redetermination Appeal Template Letter*
Template letter to request a First-Level/Second-Level Appeal by a Medical Advisor for the prior authorization denial of a drug.
Commercial Claim Denial Appeal/Redetermination Template Letter*
Template letter to request a First-Level/Second-Level Appeal by a Medical Advisor of the denial of a drug.
Template letter to appeal for coverage if payer’s policy has denied access to a product.
Alternative Funding Program (AFP) Appeal Template Letter*
This template is offered as a resource to use when appealing the denial of coverage for a BMS Medication by the patient’s health benefits company.
*Template letters are provided as examples of potential correspondence.
Checklists
Peer-to-Peer Medical Checklist
If a patient has been denied coverage for a medication by a payer, a peer-to-peer review may be warranted for approval. Review this checklist to support the patient’s treatment rationale.
Letter of Medical Necessity Checklist
Critical points to consider covering in a Letter of Medical Necessity if your patient has applied for and been denied health plan coverage for a BMS product you wish to prescribe.
Guides
A user guide for our online provider portal designed to help you assist patients with enrolling in BMS Access Support® programs.
A Guide to Electronic Benefits Reverification (eBRV)
A guide to reverifying benefits for your patients currently enrolled in BMS Access Support and receiving BMS medications.
Getting Started with BMS Access Support: An HCP Guide
An introduction to BMS Access Support for healthcare professionals.
A step-by-step process map of the healthcare professional reimbursement journey.
An overview of coverage decisions, potential outcomes, and how to begin an exception or appeal process.
CMS Forms and Documents
Medicare Redetermination Request Form (Form CMS-20027)
Form to request an appeal (redetermination) of Medicare’s coverage or payment decision.
Medicare Reconsideration Request Form (Form CMS-20033)
Form to request a reconsideration of Medicare’s initial decision from your plan.
Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)
Form to request a Medicare Hearing by an Administrative Law Judge.
Medicare Appointment of Representative Form (Form CMS-1696)
Form to request a representative for a Medicare appointment.
Patient Resources
Understanding Your Healthcare Benefits
Information about how health insurance may help patients pay for treatment.
A guide to Medicare Part D drug benefit design.
A guide to Medicare low-income subsidy for patients with limited income or resources.
An overview of services BMS Access Support provides to patients.
Patient Reimbursement Process Map
A step-by-step process map of the patient reimbursement journey.
Patient Treatment Journey Journal
A journal that may help patients stay organized and take an active role throughout the treatment journey.
A guide explaining how patients can appeal a prescription denial.
A guide for patients to discuss appealing a prescription denial with their doctor.
A letter template that patients can submit to their insurer to appeal a medication denial.
Medicare Prescription Payment Plan Flashcard
A guide to help patients understand how the Medicare Prescription Payment Plan works and if enrolling may benefit them.
The educational videos below are available to help you and your patient navigate the insurance coverage process and learn how BMS Access Support® can help support the treatment journey.
What is an Explanation of Benefits (EOB)?
If this is not a bill, then what is it? Watch this video and get a better understanding of the Explanation of Benefits (EOB).
This video is intended for your patients.
What is Health Insurance?
Health insurance can have a lot of moving parts. Watch this video and understand the basics of health insurance, coverage, payments, and more.
This video is intended for HCPs.
Get to Know BMS Access Support
Learn about the services we provide to support the patient journey, including coverage assistance, reimbursement information, and educational resources.
This video is intended for HCPs.
Select each option below to find answers to some of the most commonly asked questions about BMS Access Support.
Patients are the reason behind what we do. BMS Access Support is dedicated to helping patients access their prescribed BMS medications. We provide benefits reviews, prior authorization and appeals support, and reimbursement information to support patient access. Additionally, we offer financial support options and educational resources to support patients throughout their treatment journey.
You can contact BMS Access Support by calling 1-800-861-0048. Patient Access Specialists are available Monday through Friday, 8 AM – 8 PM ET. You can also request a visit from a BMS Access and Reimbursement Manager through our virtual Access Assistant.
Patients can be enrolled in the BMS Access Support program through our online enrollment process. To begin, select the medication prescribed for your patient and complete and sign the enrollment form on the Enrollment page. After you submit the form, your patient will receive an email prompting them to complete and sign their portion of the form.
If you prefer to enroll patients manually, download the appropriate form from the Enrollment page based on your patient's prescribed medication, then fax the completed form to the number listed on the form.
Patients with commercial insurance may be eligible for a $0 co-pay offer* through the BMS Access Support Co-Pay Assistance Program (subject to an annual maximum benefit).
*Restrictions apply. Please see full Terms and Conditions, including complete eligibility requirements, by clicking the appropriate link below:
For patients who have government insurance (Medicare, Medicaid, or TRICARE) or who do not have insurance, independent charitable foundations may be able to assist with treatment costs. BMS Access Support may be able to provide information about independent charitable foundations that may be able to help.
It is important to note that these charitable foundations are independent from Bristol-Myers Squibb Company. Each foundation has its own eligibility criteria and evaluation.
BMS Access Support may be able to provide benefits reviews, prior authorization (PA) assistance, and appeals process support for enrolled patients on select BMS medications.
The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.
Select your patient's prescribed medication on the Codes & Coverage page to view product-specific access and reimbursement information, including billing & diagnosis codes, reimbursement & coding guides, distribution information, and additional coverage support offerings.
The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.
