Forms

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Contracting, Credentialing and Practice Changes

• Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.
• New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource PASSE™ provider. Need help? Refer to the Navigate User’s Guide for Completing New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2100.
• Provider Change Request Form (coming soon) – Submit this form to alert CareSource PASSE to report a change within your practice.
• Navigate Provider Attestation Form– Submit this form to attest to practice competency prior to working with CareSource PASSE.
• Navigate CCVS Provider Authorization and Release Form – Submit this form to authorize release of credentialing information to CareSource PASSE.
• Navigate Organizational Credentialing Application – This form should be completed by organization/facility for credentialing.
• Navigate HCBS Credentialing Application – This form should be completed by HCBS providers to be credentialed with CareSource.
• Navigate Debarment Form – Use this form to provide ownership of disclosure information.
• Navigate CareSource PASSE Common Roster Template – This form should be completed by large facilities needing to add a large number of providers. Providers may attach the completed form to their New Health Partner Contracting Form application, or email the form to us if they’ve already filled out an application.
• Provider Maintenance Form – Use the Provider Portal to alert CareSource PASSE to changes in your practice. Log in to the portal and select “Provider Maintenance” from the navigation.

Reporting

• Navigate Incident Report Form – To report an incident, please fill out the Navigate Arkansas PASSE Incident Report Form and email it to CareSource PASSE.

Member-Related Forms

• Navigate Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource members.

Pharmacy Prior Authorization

• Navigate Hepatitis C Virus (HCV) Medication Therapy Request Sheet – Submit this form to request prior authorization for hepatitis C treatment.
• Navigate Pharmacy Prior Authorization Request Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource PASSE member’s Preferred Drug List (PDL).
• Navigate Specialty Pharmacy Prior Authorization Request Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications.
• Navigate Statement of Medical Necessity for Adult Use of a C-II stimulant – Submit this form to request prior authorization to prescribe a C-II stimulant for patients 19 years of age or older with attention-deficit/hyperactivity disorder (ADD/ADHD).
• Navigate Statement of Medical Necessity for Xolair® (Omalizumab) – Submit this form to request prior authorization to prescribe Xolair (Omalizumab).
• Navigate Synagis® Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• Navigate Vivitrol® Statement of Medical Necessity – Submit this form to request prior authorization to prescribe Vivitrol.

Medical Prior Authorization

• Navigate Medical Prior Authorization Request Form – Submit this form to request prior authorization for a medical service.

HCBS/Waiver Provider Authorization

• Home & Community Based Services (HCBS)/Waiver Provider Authorization (coming soon) – Submit this form to request prior authorization for a HCBS/Waiver service.

Claims

• ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Pharmacy Paper Claims Form – Submit this to Express Scripts^® (ESI) using the instructions on the form.
• Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
• Navigate Overpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.
• Navigate Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource PASSE.

Appeals

• Navigate Provider Appeal Form – Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
• Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.

Fraud, Waste and Abuse

• Navigate Fraud, Waste and Abuse Reporting Form – Submit this form to report suspected fraud, waste or abuse.