Forms

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HAP CareSource Provider Change Form – Use this form for changes to existing provider information.

Member-Related Forms

Navigate Coordination of Healthcare Exchange of Information Form – Behavioral health providers should use this form when referring members to primary care and other health services to promote safe and effective coordination of care.
Health Risk Assessment – Healthy Michigan Plan (HMP) beneficiaries work in collaboration with their health care provider to complete a standardized HMP Health Risk Assessment (HRA) and identify health behavior goals.
Navigate PCP Change Request Form – Members/providers may submit this form to request a change in primary care provider (PCP).
Navigate Provider Initiated Dismissal Form – Submit this form to request a primary medical provider (PMP) initiated member reassignment to another PMP.

Navigate Pharmacy Prior Authorization Form – Submit this form to request a prior authorization for a medication to be processed under the pharmacy benefit.
Navigate Specialty Pharmacy Prior Authorization Request Form – Submit this form to request a prior authorization for a specialty medication to be processed under the pharmacy benefit OR a physician administered drug to be processed under the medical benefit

Navigate Medical Prior Authorization Request Form – Submit this form to request prior authorization for a medical or behavioral health service.

ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
Navigate Claim Refund Check Form – Mail your refund check, this form and any other required documentation to HAP CareSource.
Navigate Overpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.
Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
Navigate AHS Consent Forms Instruction
Navigate Claims Dispute Form

Navigate Provider Appeal Form – Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
Navigate Expedited Appeal Form – Submit this form to request an expedited appeal for a claim denial or a medical necessity/utilization management decision.
Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.