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Forms & Documents

The following forms are for use by providers and Hospitals. Several member services documents are included for reference. If you have any questions, please contact our Provider Hotline at (866) 231-1821.
 

Administrative Review 
pdf Administrative Review Request Form - Provider
pdf Appointment of Representative Statement
pdf ER Medical Review Request
pdf Complaint Request Form - Provider
pdf Grievance Form - Member
pdf PCP Change Request Form
pdf PCP Request for Transfer of a Member


Authorizations

pdf Abortion Certificate of Necessity Form

pdf Avesis Frequently Asked Questions for Providers

pdf CareCore National FAQs for Providers

pdf DME Ancillary Services Request

pdf Home Health Services Request

pdf Hysterectomy Information

pdf Hysterectomy Prior Receipt Acknowledgement Form

pdf Informed Consent for Voluntary Sterilization

pdf Inpatient Authorization Request

pdf OB Hospital Services Authorization and Notification Requirements

pdf Outpatient Authorization Request

pdf Prenatal Notification

pdf Provider Attestation for Outpatient Therapy Services

pdf Request for Referral/Certification

pdf Skilled Therapy Services (OT/PT/ST) Prior Authorization
 

Behavioral Health

pdf Detox and Substance Abuse Rehab Service Request

pdf Electroconvulsive Therapy Service Request

pdf Initial Outpatient Service Request

pdf Inpatient, Sub-acute and CSU Service Request
pdf PHP and IOP Service Request

pdf Psychological/Neuropsychological Testing Service Request

pdf Residential Treatment Service Request

pdf Routine Outpatient Services Request
 

Billing Guidelines

pdf Federally Qualified Health Center Services (FQHC)/Rural Health Clinic (RHC)

pdf Health Check Services

pdf Behavioral Health Providers

pdf Community Service Boards (CSB) or CORE Providers
 

Brochures

pdf All About WellCare

pdf Medical Management Objectives

pdf PaySpan Health - EFT/ERA Services

pdf Provider Responsibilities

pdf What is Managed Care?
 

Claims

pdf CMS 1500 Submission Sample

pdf Coordination of Benefits Form

pdf Dental Claims / Encounter Guide

pdf Institutional Claims / Encounter Guide

pdf NDC Reporting Guidelines

pdf Outbound Benefit Enrollment Guide

pdf Professional Claims / Encounter Guide

pdf Taxonomy Guide 

pdf UB04 Submission Sample
 

Cultural Competency

pdf Cultural Compentency Program and Plan
 

"How To" Guides

pdf Disease Management Program

pdf Frequently Asked Questions

pdf Prenatal Notification & High-Risk OB Program

pdf Requesting an Authorization

 

Member Services  

pdf Incident Report

pdf Member Intervention Form

pdf Prenatal Reward Form
 

Pharmacy Services

pdf Hepatitis C Treatment Prior Authorization Form

pdf Medicaid Coverage Determination Request Form

pdf Medicaid Medication Appeal Request Form

pdf Enternal Nutritional Supplement Form

pdf Injectable/Infusion Form

pdf Suboxone/Buprenorphine Prior Authorization

pdf Synagis Prior Authorization
pdf Zubsolv Prior Authorization

 

Quick Reference Guide

pdf Medicaid

 

Telemedicine

pdf Intake Form

pdf Brochure

pdf Frequently Asked Questions
 

Website Assistance

pdfWebsite Registration: Large Groups/IPAs


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Last modified: 05/04/2015
 
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