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.

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

Forms to Update Your Information

• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource provider. Need help? Refer to the Navigate Step-by-Step Join Our Network Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-844-607-2831.
• Coordination of Healthcare Exchange of Information Form
  Use this form to exchange information between health care providers and coordinate care on behalf of members.
• HIPAA Consent Form
  This form is used for members to consent to sharing health information with health care providers.
• Provider Education Attestation Form
  Use this form to provide attestation of completing education requirements.
• Navigate Organizational Provider Credentialing Application Form
  Organizations and facilities use this form to supply demographic, certification and billing information and submit the form along with the New Health Partner Contract Form.
• Provider Debarment Form 
  Use this form to provide attestation of provider information and submit it along with your New Health Partner Contract Form.
• Provider Maintenance Form
  The preferred method of submission of changes to your practice is the Provider Portal. 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.
  • As an alternative method, Provider Maintenance may also be submitted completing the Indiana Health Coverage Programs (IHCP) Managed Care Entity (MCE) Practitioner Enrollment Form and emailing to ProviderMaintenance@CareSource.com.
• Rendering Provider List
  Use this spreadsheet to list all provider information for rendering providers.
• Navigate 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.

Claims-Related Forms

• Navigate Overpayment Recovery Form
  Submit this form to offset overpaid claims against a future payment.

• Navigate Claims Dispute Form
  Submit this form if you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information.

• Navigate Claim Recovery Refund Check Form
  Submit this form in its entirety to assist with accurate and timely reprocessing of your claims.

• ECHO Health Enrollment Form
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.

• Non-Participating Provider Profile Form
  Providers who are not in the CareSource network must complete the Non-Participating Provider Profile Form in order to submit claims. After we receive your profile, you will receive credentials to log in to the Provider Portal, where you can submit claims electronically.

  The form can be located on our Claims page.

• Navigate Provider Standard Appeal Form
  Providers must exhaust the claim dispute process as outlined above before filing a claim appeal.

  Claim appeals must be submitted:

  • Within 60 days of the resolution of the dispute process
  • Through the Provider Portal (most efficient method) or the Provider Clinical/Claim Appeal Form

  Claims appeals filed without first submitting a dispute will not be processed.

  Arbitration Process: If you are dissatisfied with the decision of the claim appeal, you may submit the matter to binding arbitration. The binding arbitration process must be conducted in accordance with the rules and regulations of the American Health Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act as adopted in the State of Indiana at IC-34-57-2-2.

Member-Related Forms

• Coordination of Healthcare Exchange of Information Form
  Use this form to exchange information between health care providers and coordinate care on behalf of members.

• HIPAA Consent Form
  This form is used for members to consent to sharing health information with health care providers

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

• 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. 

• Medically Frail FAQs
  For additional information about medically frail referrals and determination, access the FAQ document.

• Navigate Medically Frail Referral Form
  Use this form to make a referral for medically frail determination.

• Medical Prior Authorization Form
  Submit this form to request prior authorization for a medical procedure.

• Navigate Member Reassignment Form
  Please complete the Member Reassignment Form if you would like to remove a patient from your panel.

• Pre-Birth Selection Form
  Submit this form to request primary medical provider (PMP) assignment for a member’s baby prior to birth.

• 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 Forms