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Medical and Other Prior Authorization
- Prior Authorization Request Form– Fillable E-Form – Submit this form to request prior authorization for a medical procedure.
- Prior Authorization Request Form – Print Version – Submit this form to request prior authorization for a medical procedure.
- Abortion, Sterilization and Hysterectomy Forms – Humana – CareSource uses the Kentucky state forms to authorize abortions, sterilizations and hysterectomies. The abortion, sterilization and hysterectomy forms are identified as forms MAP235, MAP250 and MAP251 respectively.
- ECHO Health Enrollment Form – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
- Non-Participating Provider Profile Form – Submit this form with a non-participating provider’s claim.
- Request to Update NPI and/or Taxonomy Code – Submit this Kentucky state form to update NPI and/or taxonomy codes.
- Kentucky Medicaid MCO Provider Appeal Request 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.
- External Review Request Form – Submit this form to request an external review on behalf of a member.
- Provider Grievance Form – Submit this form to file a grievance/complaint.