Provider Forms

Download and print commonly used forms. All forms are in PDF format.

Telemedicine Services

Use this form to let us know if your practice offers telemedicine services.  

Professional Claim Adjustment Request

Use this form to file an adjustment or report an over payment to a professional claim.

Institutional Claim Adjustment Request

Use this form to file an adjustment or report an over payment to an institutional claim.

Continuity of Care for Enrollees – Authorization Transfer Request

This form is used to request transfer of authorization from a previous insurance carrier to BCBSWY.

Other Coverage Questionnaire

This form is used to verify the health care coverage of your patients and to assist you in determining primary and secondary coverage.

Practice / Office Information

Use this form to update provider or office contact information with BCBSWY.

Prior Authorization Request

This form may be used by a health care provider to notify BCBSWY of a patient’s intent to receive services requiring prior certification.

Voluntary Refund Request

Use this form to submit a voluntary refund request for dates of service January 1, 2019 and prior.

No Surprises Price Negotiation

This form is used to request a price negotiation as outlined under No Surprises Act.

Dental Continuation of Care Request Form

This form contains important information about your dental health care provider’s status.

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Request for Claim Adjustment Instructions

How do I file an adjustment to a claim?

Complete a Professional or Institutional Claim Adjustment Request Form.

The following requests require medical documentation needs to be uploaded through Availity:

  • Units Change Increase
  • Appeals – Pricing
  • Appeals – Benefits

If you are unable to upload supporting documentation through Availity, please reach out to Provider Services at 1-800-442-2276.

The remaining requests on the Claims Adjustment Form do not require medical documentation and should not be submitted through Availity:

The following additional information is needed to ensure timely processing:

  • Include the date of service and claim number of the claim you are requesting the change.
  • Please give a detailed explanation of the changes you are requesting.
  • When submitting chart notes or medical information, submit an explanation of why this information is being submitted. If the information being submitted was requested by Blue Cross Blue Shield of Wyoming, please attach a copy of the request.
  • When submitting claim appeal letters, please attach supporting documentation (chart notes, X-ray reports, etc.).
  • The Request for Professional Claim Adjustment form should be used for services submitted on a CMS-1500.
  • The Request for Institutional Claim Adjustment form should be used for services submitted on a UB-04.
  • Include the full name (first and last name) and telephone number of the person submitting the adjustment request.
  • Submit only one claim per inquiry form.
  • When using these forms, enter the total amount of the claim prior to the adjustment.
  • Do not separate supporting documentation through multiple submission channels; use only one channel per appeal or adjustment submission. For example, when submitting an appeal through Availity, do not send supporting documentation via fax or mail. Likewise, if submitting an adjustment via fax, do not submit additional documentation for the same claim mail. Keep all supporting documentation and claims together in a single submission channel.


Send written request to:

PO Box 2266
Cheyenne, WY 82003

Fax requests to: (307) 432-2942

Coordination of Benefits

Coordination of benefits can be a complicated issue and is one of the top reasons for overpayments to providers. In order to assist you with determining primary and secondary coverage, we have listed some general guidelines for you to follow. Should you have questions regarding coverage, contact the plan who issued the coverage prior to filing a claim for services.

The first of the following rules that describes which plan pays as primary is the rule to use

Rule # 1- Dependent or Non-Dependent

The plan that covers the person other than as a dependent, for example as an employee, member, subscriber, or retiree is primary. The plan that covers the person as a dependent is secondary.

Rule # 2 – Child Covered Under More Than One Plan

The primary plan is the plan of the parent whose birthday is earlier in the year if:

  • The parents are married;
  • The parents are not separated’;
  • A court decree awards joint custody without specifying that one parent has the responsibility to provide healthcare coverage;
  • If both parents have the same birthday, the plan that has covered either of the parents longer is primary.

If you have any questions regarding coordination of benefits for a Blue Cross Blue Shield of Wyoming member, please contact our Member Services department at 1-800-442-2376