Forms

You may need to download Adobe Acrobat Reader to open these files.

Update Your Information

• New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource^® provider.
• Provider Maintenance Form – Use the Provider Portal to alert CareSource to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation. If you are unable to access the Provider Portal, please contact your Health Partner Engagement Specialist for assistance.
• Navigate Provider Debarment Form – Use this form to provide attestation of provider information and submit it along with your New Health Partner Contract Form
• Navigate Organizational Provider Credentialing Application Form – Use this form to supply demographic, certification and billing information and submit the form along with your New Health Partner Contract Form.
• Navigate New Provider Step-by-Step Guide to Become a CareSource Health Partner – Use this guide for instructions on becoming a CareSource participating provider.
• W-9 Tax Form – Use this form to provide your Taxpayer Identification Number (TIN) and certification information. Please submit this form along with your New Health Partner Contract Form.

Member-Related Forms

• • Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
  • Navigate Coordination of Healthcare Exchange of Information Form – Use this form when referring members to behavioral health services to promote safe and effective coordination of care.
  • Provider Referral For Member Education Form – Submit this form to refer a member for education before requesting a primary medical provider (PMP) change.
  • Member Reassignment Form – Submit this form to request a PMP change for the member.
  • Navigate Pre-Birth Selection Form – Submit this form to request primary medical provider (PMP) assignment for a member’s baby prior to birth.
  • PMP Change Request Form  – Submit this form to request a patient be moved on to your panel.
  • Navigate Medically Frail Referral Form – Submit this form to refer a member for a medically frail assessment.
    • Navigate Medically Frail FAQs
  • Navigate Substance Use Disorder Quality Improvement Project Case Management Referral Form – Submit this form to engage members admitted to the emergency department with substance use disorder (SUD) in case management.
  • HIPAA Consent Form – This form is used for members to consent to sharing health information with health care providers
  • Life Services Referral Form – CareSource Life Services® is a program that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer a patient to this program. 

Pharmacy Prior Authorization

• Navigate Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe medications under the pharmacy benefit.
• Navigate Specialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the CareSource Medicaid PDL.
• Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• Non-Preferred Buprenorphine/Naloxone Prior Authorization Request Form – Submit this form to request prior authorization for buprenorphine and medicines containing buprenorphine. 
• Extended Release Opioid Prior Authorization Form – Submit this form to request prior authorization for extended release opioids.
• Navigate Immediate Release Opioid Prior Authorization Form – Submit this form to request prior authorization for immediate release opioids.
• Navigate Diabetes Testing Supplies Prior Authorization Form –Submit this form to request prior authorization to Diabetes Testing Supplies.
• Navigate Concurrent Benzodiazepine and Opioid Prior Authorization Form –Submit this form to request prior authorization for concurrent Benzodiazepine and Opioid prescriptions.

Medical Prior Authorization

• Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure.
• Navigate SUD Residential and Inpatient Hospitalization Form – Submit this Prior Authorization Request for SUD Residential or SUD Partial Inpatient Hospitalization.

Claims

• Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims. 
• ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
• Navigate Overpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.

Disputes and Appeals

• Navigate Claim Dispute Form – Submit this form to request a claim dispute.
• Navigate Provider Clinical Appeal Form – Submit this form to request an appeal for a medical necessity/utilization management decision.
• Navigate Provider Claim Appeal Form – Submit this form to request an appeal for a claim denial. This form can be used after a claim dispute has already been submitted.
• 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

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