Bristol-Myers Squibb is committed to helping appropriate patients get access to our medications by providing access and reimbursement support services.

This information is intended for U.S. healthcare professionals and/or healthcare professionals involved in healthcare reimbursement.

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INDICATIONS AND USAGE /
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Forms and Documents

Enrollment Form

Download the Enrollment Form

Patient Authorization and Agreement Form

To enroll or conduct a Benefits Review, please visit this site from your desktop computer.

Claim Documents

Office Support Tools

Medical Necessity Template Letter

Letter of Medical Necessity Checklist

Prior Authorization Denial/Redetermination Appeal Template Letter

Commercial Claim Denial Appeal/Redetermination Letter

Open Access Template Letter 

CMS Forms and Documents

Medicare Redetermination Request Form (Form CMS-20027)

Medicare Reconsideration Request Form (Form CMS-20033)

Request for a Medicare Hearing by an Administrative Law Judge (Form CMS-20034A/B)

Medicare Appointment of Representative Form (Form CMS-1696)

Patient Resources

Understanding Your Healthcare Benefits

Patient Reimbursement Process Map

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.

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Request a visit from a BMS Access & Reimbursement Manager

 
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Use of the information on this site is subject to the terms of our Legal Notice and Privacy Statement. The coding, coverage, and payment information contained within this website is current as of 03/17.

427US1605615-01-01 03/17