Behavioral Health Forms

This page contains Behavioral Health forms for providers to use when communicating with Highmark Blue Cross Blue Shield of Western New York.

Behavioral Health Inpatient Authorization Request Form
Communication Document for Behavioral Health Specialist To Primary Care Physician
Discharge Summary Fax Template
Outpatient Behavioral Health (BH) - ABA Requests: Service Authorization Request
Functional Behavior Assessment Autism Form
Out-of-Plan Referral Form
Consent for Case Management Services for Inpatient Residential Treatment Care
- Applies to FEP members.
- Fax consent form and treatment plan to 1-833-581-1867.

Residential Treatment Center (RTC) must be accredited by a nationally recognized organization and licensed by the state, district, or territory to provide residential treatment for medical conditions, mental health conditions, and/or substance abuse.

Pre-Admission Requirements:

Precertification prior to admission
A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC), and case manager in the Local Plan where the RTC is located prior to admission.
Member must be enrolled and participating in case management through the Local Plan when the care is medically necessary for treatment of a medical, mental health, and/or substance abuse condition.

FEP Nondiscrimination Notice

Last updated on 2/17/2022 2:51:34 PM

Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.

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Behavioral Health Forms

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