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CareSource - Michigan Providers - Provider Materials - Forms

Forms

CareSource has many materials for providers. These are listed below. Please click on the link to open the item. Each item will open as a PDF. You need Adobe Acrobat Reader to open these files. If you do not have Adobe Acrobat Reader, you can download it here.

Medicaid

Claims

Provider Clinical/Claim Appeal Request Form - Updated! June 2011
Claims Recovery Request Form
Provider Claim Research Request
Provider Profile Form

Medical

Pharmacy

Specialty Pharmacy Prior Authorization Request - Updated! May 2011
Non-Formulary Drug Prior Authorization Form
Preferred Drug List

Other

CareSource Corporate Compliance Plan
Fraud, Waste, and Abuse Reporting Form
2008 Synagis Webinar - 09/24/08
Fair Hearing Plan - Updated! August 2011

Medicare

Pharmacy

Prescription Drugs Appeal Policy
Prescription Drugs Coverage Determination Online Form - NEW! January 2012
Prescription Drugs Coverage Determination Form (pdf) - Updated! January 2012
Prescription Drugs Redetermination Online Form - NEW! January 2012
Prescription Drugs Redetermination Form (pdf) - Updated! January 2012
Prescription Drugs Exceptions to Formulary Policy

Medical and other

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