Forms and resources for you and your patients

Blank CMS-1500 Form

Standard claim form for physician office.

Blank UB-04/CMS-1450 Form

Standard claim form for hospital outpatient.

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.

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.

Open Access Template Letter^*

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.

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.

My BMS Cases User’s Guide

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.

HCP Reimbursement Process Map

A step-by-step process map of the healthcare professional reimbursement journey.

Exceptions & Appeals Guide

An overview of coverage decisions, potential outcomes, and how to begin an exception or appeal process.

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.

Understanding Your Healthcare Benefits

Information about how health insurance may help patients pay for treatment.

A Guide to Medicare Part D

A guide to Medicare Part D drug benefit design.

Low-Income Subsidy Brochure

A guide to Medicare low-income subsidy for patients with limited income or resources.

Patient Brochure

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.

Patient Bill of Rights

A guide explaining how patients can appeal a prescription denial.

Appeals Discussion Guide

A guide for patients to discuss appealing a prescription denial with their doctor.

Appeal Template Letter

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.