Forms
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Update Your Information
- 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.
- Provider Debarment Form
Member-Related Forms
- Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
- 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.
- 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.
- Medically Frail Referral Form – Submit this form to refer a member for a medically frail assessment.
- 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.
Pharmacy Prior Authorization
- Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe medications under the pharmacy benefit.
- 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.
- Immediate Release Opioid Prior Authorization Form – Submit this form to request prior authorization for immediate release opioids.
- Diabetes Testing Supplies Prior Authorization Form –Submit this form to request prior authorization to Diabetes Testing Supplies.
- 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.
- SUD Residential and Inpatient Hospitalization Form – Submit this Prior Authorization Request for SUD Residential or SUD Partial Inpatient Hospitalization.
Claims
- Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
- ECHO 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.
- Overpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.
Disputes and Appeals
- Claim Dispute Form – Submit this form to request a claim dispute.
- Provider Clinical Appeal Form – Submit this form to request an appeal for a medical necessity/utilization management decision.
- 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.
- 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.