Forms
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Update Your Information
Please submit any changes within your practice using the Provider Maintenance Form on the Provider Portal. Simply login to the Portal and select “Provider Maintenance” from the navigation bars on the left-hand side of the page. You can update CareSource with changes such as:
- Adding or deleting a provider to a group
- Changing an address or phone number
- Adding new restrictions or capacity limitations
The information will be submitted electronically to CareSource and you will receive an email verifying your requested changes.
NOTE – To change your Tax ID number, or update your IRS name, you must make those changes through an amendment to your contract, not through maintenance. You can make those changes using the 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 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.
- 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.
- Potentially 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.
- 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 or SUD Partial Hospitalization Form – Submit this Prior Authorization Request for SUD Residential or SUD Partial 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.
- Itemized 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.
- 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.