Forms
We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.
Request Forms
- Coordination of Care and Release of Information Form (coming soon) – Use this form to share patient care information with another provider.
- Primary Care Manager (PCM) Change Request Form – Use this form to submit a PCM change request.
Medical Prior Authorization Forms
- Medical Prior Authorization Request Form – Submit this form to request medical prior authorization.
- Nursing Facility Form (coming soon) – Submit this form to request prior authorization for a nursing facility admission.
- Outpatient Behavioral Health Prior Authorization Form (coming soon) – Submit this form to request prior authorization for outpatient behavioral health services.
- Urine Drug Screen Prior Authorization Form (coming soon) – Submit this form to request prior authorization for urine drug screening for patients with a substance use disorder.
- SUD 1115 Waiver Universal Prior Authorization Form (coming soon) – Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization Substance Use Disorder (SUD) services.
Claims Forms
- Claim Refund Check Form – Mail your refund check, this form and any other required documentation to TRICARE Prime Demo.
- CMS 1500 Health Insurance Claim Form (coming soon) – Waiver services providers who cannot log into the provider portal can use this form to submit a claim. Access instructionsto complete the form and a list of valid service codes.
ECHO Health Enrollment (coming soon) – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
- Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
- Overpayment Recovery Form – Providers may submit Recovery Requests via the provider portal.
- Provider Standard Claim Dispute Form (coming soon) – Submit this form to dispute a standard claim. The best way to submit is via the provider portal. It can also be mailed to the address on the bottom of the form.
Appeals Forms
- Appointment of Representation (AOR) Form (coming soon) – Submit this form if you are not a physician or a physician representative.
Consent for Provider to File an Appeal on Patient/Beneficiary’s Behalf (coming soon) – Submit this form to request an appeal on behalf of a beneficiary.
- Provider Appeal Request Form (coming soon) – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
- Waiver of Liability Form for Claim Appeals (coming soon) – Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.
Dental Forms
- ADA Dental Claim Form Instructions (coming soon) – Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.
- Dental EFT Enrollment Authorization Agreement Form (coming soon) – Follow the instructions to enroll in Scion Dental’s EFT program.
- ODJFS Dental Services Prior Authorization Form (coming soon) – Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.
- TMD Screening Examination Form (coming soon) – Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.
Fraud, Waste and Abuse
- Fraud, Waste and Abuse Reporting Form(coming soon) – Submit this form to report suspected fraud, waste or abuse.
Prior Authorization
- Utilization Management Prior Authorization Form (coming soon) – Submit this form to request prior authorization from Utilization Management for medical and behavioral health services (such as inpatient admission or home health care) or for durable medical equipment.
- Pharmacy Prior Authorization Medical Drug Prior Authorization Form (coming soon): Submit this form to request a prior authorization to prescribe provider administered drugs covered and reimbursable by CSMV under the medical benefit.