Forms

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Contracting and Practice Changes

• 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.
• 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.

Member-Related Forms

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

Pharmacy Prior Authorization

• Navigate Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the drug formulary. 
• Navigate Specialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the drug formulary.
• Navigate Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• Navigate Compound Prior Authorization Form – Submit this form to request prior authorization to prescribe compounds.
• Navigate Hyaluronic Acid Injections Prior Authorization Form – Submit this form to request prior authorization to prescribe Hyaluronic Acid Injections.

Medical Prior Authorization

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

Claims

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

Appeals

• Navigate 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

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