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 User’s Guide for Completing the New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2101. | 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. |
Member-Related Forms
Coordination of Care and Release of Information Form Use this form to coordinate care between providers and to release member information. | Use this form to submit PCP change requests. |
Pharmacy Prior Authorization Forms
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. | Synagis Prior Authorization Form Submit this form to request prior authorization to prescribe Synagis. | ||
Medical Prior Authorization Form(s)
Medical Prior Authorization Form Submit this form to request prior authorization for a medical procedure. |
Claims Forms
Submit this form, along with your refund check and any other required documentation, to CareSource North Carolina Co. | Submit this form to enroll with ECHO Health, our electronic funds transfer partner. |
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
Submit this form to request an expedited appeal. | 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. |