This page is a repository of forms and documents listed by function. The information is intended for use by Providers and Hospitals. Documents related to Member Services are included for your reference. If you have any questions, please contact our Provider Hotline at (866) 231-1821.      

Administrative Review

 Administrative Review Request Form - Member
 Administrative Review Request Form - Provider
 Appointment of Representative Statement
 Appeal Request Form for ER Med Review
 Complaint Request Form - Provider
 Grievance Form - Member
 PCP Request for Transfer of a Member

Authorizations

  Abortion Certificate of Necessity Form
 Ancillary Services Authorization Request Form
 Hospice ESRD Placement Referral Report
 Hysterectomy Information
 Hysterectomy Prior Receipt Acknowledgement Form
 Informed Consent for Voluntary Sterilization
 Inpatient Authorization Request Form
 Outpatient Authorization Request Form
 Prenatal Notification Form
 Provider Attestation for Outpatient Therapy Services
 PT, OT & ST for Children with Chronic Conditions
 Request for Referral/Certification

Benefit Grids

  Georgia Medicaid Benefit Grid
 PeachCare for Kids Benefit Grid

Brochures

  All About WellCare
 Medical Management Objectives
 PaySpan Health - EFT/ERA Services
 Provider Responsibilities
 What is Managed Care?

Claims

 Applicable Co-Payments
 CMS 1500 Guidelines for Paper Claims
 CMS 1500 Submission Sample
 Coordination of Benefits Form
 Demographic Information for Non-Participating Authorizations/Claims
 ER Claims Reconsideration Form
 Institutional Claims Guide
 Institutional Encounter Guide
 Professional Claims / Encounter Guide
 UB-04 Guidelines for Paper Claims
 UB-04 Submission Sample

"How To" Guides

  Disease Management Program
 Filing an Administrative Review - Members
 Filing an Authorization-Related Claim Appeal - Providers
 Filing a Claim Appeal - Providers
 Filing a Complaint - Providers
 Filing a Grievance - Member
 Frequently Asked Questions
 Guide to Accessing Customer Service
 How to Verify Eligibility
 Pharmacy Services Guide
 Prenatal Notification & High-Risk OB Program
 Requesting an Authorization
 Tips on How to File Claims
 W-9 Contact Information
 Web Access

Member Services

 Incident Report

 Member Data Change Form

 Member Intervention Form

 Member Prenatal Reward Form English

 Member Prenatal Reward Form - Spanish

Pharmacy Services

 Accu-Chek® Order Form

 Abbreviated Preferred Drug List

 Bayer® Order Form

 Medicaid Coverage Determination Request Form

 Enternal Nutritional Supplement Form

 Injectable/Infusion Form

 Preferred Drug List

 Synaqis Order Form

Provider Newsletters

 Georgia Provider Newsletter - Spring 2008
 Georgia Provider Newsletter - Winter 2007

 Georgia Provider Newsletter - Fall 2007

 Georgia Provider Newsletter - Summer 2007

 Georgia Provider Newsletter - Spring 2007

Quick Reference Guides

 Quick Reference Guide - Medicaid

 Quick Reference Guide - No Authorization Required CPT Code List

Web Tutorials

 Electronic Funds Transfer (EFT) User's Guide

 Provider Portal Batch Eligibility Tutorial