Enrollment Form
Download the Oncology Enrollment Form
Oncology 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
Medically Unlikely Edit (MUE) Overview Flashcard
Medically Unlikely Edit (MUE) Appeal Template Letter
Medical Necessity Template Letter*
Letter of Medical Necessity Checklist
Prior Authorization Denial/Redetermination Appeal Template Letter*
Commercial Claim Denial Appeal/Redetermination Template Letter*
*Template letters are provided as examples of potential correspondence.
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)
Patient Resources
Enrollment Form
Download the Rheumatology Enrollment Form
Rheumatology 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*
Prior Authorization Denial/Redetermination Appeal Template Letter*
Commercial Claim Denial Appeal/Redetermination Template Letter*
*Template letters are provided as examples of potential correspondence.
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)
Patient Resources
Enrollment Form
Download the Kidney Transplant Enrollment Form
Kidney Transplant 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*
Prior Authorization Denial/Redetermination Appeal Template Letter*
Commercial Claim Denial Appeal/Redetermination Template Letter*
*Template letters are provided as examples of potential correspondence.
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)
Patient Resources
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.