outpatient Form

BND-22-0169611 • 2-26 Page 1 of 4 Instructions: All fields in this form are required unless otherwise indicated (optional / applicable). If not completed in full, expect a delay in response. Effective Jan. 1, 2025, Blue Cross Blue Shield of North Dakota (BCBSND) providers must use the Availity Essential Provider Portal. Faxes and phone calls for preservice precertification requests will no longer be accepted unless BCBSND gives approval due to system issues. Providers outside of North Dakota without electronic access should fax this form along with clinical support records to 701-277-2971. Questions? Call BCBSND UM at 800-952-8462. If providers are unable to use Availity to submit photos or for member submitted requests, please mail request and/or photos to: BCBSND Attn: Utilization Management 4510 13th Ave. S. Fargo, ND 58121 Member Information Patient First Name Patient Last Name Patient Date of Birth Member ID (including alpha-numeric prefix) Relationship to Subscriber:
Self
Spouse
Child
Other

Service Information - Outpatient Service Type (Select One) If request is for inpatient services, please utilize Inpatient Authorization Request Form. Dental Accident
Applied Behavior Analysis Therapy
Oral Surgery Infertility
Private Duty Nursing
Anesthesia Prosthetic Device
Partial Hospitalization (Psychiatric)
Surgical
Chemotherapy
Partial Hospitalization (Substance Abuse)
Home Health Care
Transplants
Durable Medical Equipment Rental
Medical Pharmacy
Durable Medical Equipment Purchase
Diagnostic Lab Hospice
Place of Service (Select One) Ambulance (Land)
Ambulance (Air or Water)
Hospice
Office
Ambulatory Surgical Center
Partial Hospitalization Home
Outpatient Hospital
Outpatient Surgical Service Information - Outpatient Request Type (Select One) Initial (Complete Initial Service Information Section) Concurrent (Complete Concurrent Service Information Section)

Outpatient Authorization Request Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association.

BND-22-0169611 • 2-26 Page 2 of 4 Initial Service Information Start of Care Date End of Care Date (If Applicable)

Concurrent Service Information Start Care Date Previously Approved Services Start Date of Concurrent Care Request Authorization (AUTH-) number of previous request

Diagnosis Diagnosis Code(s) 1 Required (Please use additional page if more ICD-10-CM codes are required) Code (ICD-10-CM)
Description Code (ICD-10-CM)
Description Code (ICD-10-CM)
Description Code (ICD-10-CM)
Description

Procedure Code Procedure Code(s) (CPT/HCPCS, 1 Required. Please use additional page if more CPT/HCPCS are requested.) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units)

BND-22-0169611 • 2-26 Page 3 of 4 Provider Information Requesting Provider First Name Requesting Provider Last Name Fax Number (Required) Specialty/Taxonomy Code (Optional) TIN (Optional) NPI Address Line 1 Address Line 2 (Optional) City State Zip

Servicing Provider/Servicing Facility Information Service Provider First and Last Name or Facility Name Phone Number (Required) Fax Number (Required) NPI TIN (Optional) Address Suite City State Zip

Completion Information Completed by Information Completed by Name (Required) Completed by Contact Phone Number (Required) Today’s Date Contact for Additional Questions Additional Contact Name Additional Contact Phone Number

Additional Codes If Needed Diagnosis Code(s) Code (ICD-10-CM) Description Code (ICD-10-CM) Description Code (ICD-10-CM) Description

BND-22-0169611 • 2-26 Page 4 of 4 Additional Codes If Needed Diagnosis Code(s) (cont.) Code (ICD-10-CM) Description Code (ICD-10-CM) Description Code (ICD-10-CM) Description Procedure Code(s) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units)