Forms

We have compiled all of the essential forms in one place. Select the applicable form(s) for reporting, credentialing, claims, and more.

Claims Forms

• Navigate Claim Recovery Refund Check Form
• Itemized Bill Cover Sheet (coming soon)
• Member Claim Form (coming soon)
• Navigate Optum Claims Review Process FAQ
• Navigate Overpayment Recovery Form

Contracting and Practice Changes Forms

• Navigate HAP CareSource Provider Change Form 
  Use this form to submit any changes for your practice and update your information.

Fraud, Waste and Abuse Forms

• Fraud, Waste and Abuse Reporting Form

Member-Related Forms

• Navigate Special Supplemental Benefits for the Chronically Ill (SSBCI) Provider Attestation Form 
  Submit this form to confirm your patient has been diagnosed with one or more qualifying conditions and meets the CMS criteria for receiving SSBCI.

Prior Authorization Forms for Medical, Waiver and Other Services

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