Forms

Below, you’ll find essential forms and documents providers need to best serve our members.

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

Contracting and Practice Changes Forms

• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource North Carolina Co.^® provider. This form can also be used to change your tax ID number, as well as add products. Need help? Refer to the Navigate Becoming a Health Partner Step-by-Step Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2101.
• Provider Maintenance Form
  Use the Provider Portal to alert CareSource North Carolina Co. to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation bar.
  

Member-Related Forms

• Coordination of Care and Release of Information Form
  Use this form to coordinate care between providers and to release member information.
• PCP Change Request Form
  Use this form to submit PCP change requests.

Pharmacy Prior Authorization Forms

• Change in Facility Request
  Complete and submit this form to request a facility change. Applicable to medical benefit only.
  
• Compound Prior Authorization Form
  Submit this form to request prior authorization to prescribe compounds.
• Hyaluronic Acid Injections Prior Authorization Form
  Submit this form to request prior authorization to prescribe Hyaluronic Acid Injections.
• Pharmacy Prior Authorization Form
  Submit this form to request prior authorization to prescribe certain medications, as outlined in the drug formulary. 
• Specialty Pharmacy Prior Authorization Form
  Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the drug formulary.

Medical Prior Authorization Form(s)

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

Claims Forms

• Claim Refund Check Form
  Submit this form, along with your refund check and any other required documentation, to CareSource North Carolina Co.
• ECHO Health Enrollment
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
  
• Overpayment Recovery Form
  Providers may submit Recovery Requests via the Provider Portal.

Appeals Forms

• Expedited Appeal Form
  Submit this form to request an expedited appeal.
• Standard Appeal Form
  Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.

Fraud, Waste and Abuse

• Fraud, Waste and Abuse Reporting Form
  Submit this form to report suspected fraud, waste or abuse.