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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 Ancillary Services Authorization Request Form

pdf Avesis Frequently Asked Questions for Providers

pdf CareCore National FAQs for Providers

pdf Hospice ESRD Placement Referral Report

pdf Hysterectomy Information

pdf Hysterectomy Prior Receipt Acknowledgement Form

pdf Informed Consent for Voluntary Sterilization

pdf Inpatient Authorization Request Form

pdf OB Hospital Services Authorization and Notification Requirements

pdf Outpatient Authorization Request Form

pdf Provider Attestation for Outpatient Therapy Services

pdf Request for Referral/Certification
 

Behavioral Health
pdf 
Initial Outpatient Service Request

pdf Inpatient and Partial Hospitalization Service Request
pdf Intensive Outpatient and Routine Outpatient Service Request
pdf Outpatient Treatment Authorization Request Form

pdf Request for Psychological/Neuropsychological Testing

pdf Residential Treatment Authorization Request Form

pdf Health Inpatient Hospitalization Prior Authorization Tool
 

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 Abbott Meter 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 Order Form
 

Quick Reference Guides

pdf Behavioral Health

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: 04/02/2014
 

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