Forms

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

Claims

• 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.
• Navigate Overpayment Recovery Form
  Providers may submit Recovery Requests via the Provider Portal.
• Provider Standard Claim Dispute Form (Coming Soon)
  Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.

Contracting and Practice Changes

• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource^® provider. Need help? Refer to the Step-by-Step Join Our Network Guide (Coming Soon). 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 to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.

Disputes & Appeals 

• Appointment of Representative to File an Appeal on Patient/Member’s Behalf (Coming Soon)
  Submit this form to request an appeal on behalf of a member.
• Expedited Appeal Form (Coming Soon)
  If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided.
• Standard Appeal Form (Coming Soon)
  Submit this form to request an appeal for an authorization, post-service, contract or other issue.

Fraud, Waste & Abuse

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

Medical Prior Authorization

• Navigate Medical Prior Authorization Request Form
  Submit this form to request prior authorization for a medical procedure. This form should be submitted using the Provider Portal.

Member-Related Forms

• Life Services Referral Form (Coming Soon)
• Navigate Primary Care Provider (PCP) Change Request Form

Pharmacy Prior Authorization Forms 

• Navigate Compound Prior Authorization Form
  Submit this form to request prior authorization to prescribe compounds.
• Navigate Pharmacy Prior Authorization Form 
  Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource Formulary.
• Navigate Specialty Pharmacy Prior Authorization Form 
  Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the Formulary and medical drugs to be administered in an outpatient setting.