Forms

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Contracting and Practice Changes

• New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource provider. Need help? Refer to the 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 1-844-607-2831.
• Health Partner Change Request Form – Submit this form to alert CareSource to a change within your practice.

Member-Related Forms

• Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource members.
• 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.
• NavigatePre-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.
• NavigatePotentially Medically Frail Referral Form – Submit this form to refer a member for a medically frail assessment.

Pharmacy Prior Authorization

• Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe medications under the pharmacy benefit.
• 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.
• Immediate Release Opioid Prior Authorization Form – Submit this form to request prior authorization for immediate release opioids.
• NavigateDiabetes Testing Supplies Prior Authorization Form –Submit this form to request prior authorization to Diabetes Testing Supplies.
• NavigateConcurrent 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.
• NavigateSUD Residential or SUD Partial Hospitalization Form – Submit this Prior Authorization Request for SUD Residential or SUD Partial Hospitalization

Claims

• NavigateItemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims. 
• NavigateECHO Health Enrollment Form – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Nonparticipating Provider Profile Form – Submit this form with a nonparticipating provider’s claim.

• Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
• NavigateOverpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.
• NavigateItemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.

Disputes and Appeals

• Claim Dispute Form – Submit this form to request a claim dispute.
• Provider Clinical/Claim Appeal Form – Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
• NavigateConsent 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.