Provider Resources - Forms

User Agreement

Provider Network Registration Form - for login access to the BHSI Provider Network.

Significant Incident Report

Providers must report all reportable Significant Incidents following a centralize two-step process:

1.  Report the incident by telephone to the assigned BHSI Service Manager or Service Manager's supervisor within 24 hours of the incident or upon notification of the incident's occurence.

2.  A copy of all reportable incidents mustbe faxed to BHSI Service Management at 215-732-2634 or BHSI Risk Management/Detox at 215-790-4963 in addition to CBH, within 24 hours of occurrence or upon notification of an incident's occurence.

Philadelphia Department of Behavioral Health Significant Incident Report Form

Approvals and Authorizations

Approval and Authorization Instructions effective 3/1/2016 - This document provides instructions for submitting requests for approvals, authorizations and other documents.  BHSI will no longer accept faxes after 3/1/2016.  Update 3/8/2016   Powerpoint from Trainings

MA Exception Process

BHSI Concurrent Review Form - This form is used to provide the information needed for a detoxification authorization

BHSI Informed Disclosure Consent Form - This is the only version of the form that will be accepted by BHSI.

BHSI Outpatient Short Form - use this form to request approval for .5, 1A and 1B Levels of Care.


Claims Submission

BHSI will only be accepting HCFA-1500 effective 3/1/2016.  Please note that fields 29 and 30 differ from the standard HCFA-1500 in order to track food stamps and fees.  Providers who do not submit food stamps and client fees may use the standard form.

BHSI HCFA-1500 Claims Form Instructions

BHSI HCFA-1500 Claims Form

Appeals and Takebacks

Claims Appeal Form - This form is to be used when appealing claims adjudication or when proactively requesting an exemption for an adjudication rule. This form must be completed and approved by BHSI before invoices are sent.

Take Back Form - This form should be used by providers to request BHSI reversing claims that have been adjudicated cleanly. For example: The form should be used if the provider has identified someone who became CBH eligible for days/services paid for by BHSI.