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^® provider. Need help? Refer to the User’s Guide for Completing New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-800-488-0134.
• 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.

Member-Related Forms

• PCP Change Request Form
  – Members may submit this form to request a change in primary care provider (PCP).
• Life Services Provider Referral Form – Submit this form to refer a CareSource member to the CareSource Life Services program.
• Coordination of Healthcare Exchange of Information Form – Use this form when referring members to behavioral health services to promote safe and effective coordination of care.

Pharmacy Prior Authorization

• Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource NavigateFormulary.
• Hepatitis C Treatment Prior Authorization Form – Submit this form to request prior authorization for hepatitis C treatment.
• Specialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the Formulary.
• Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• NavigateMedication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form – Submit this form to request prior authorization to prescribe buprenorphine and buprenorphine-containing medications.
• Compound Prior Authorization Form – Submit this form to request prior authorization to prescribe compounds.
• NavigateHyaluronic Acid Injections Prior Authorization Form – Submit this form to request prior authorization to prescribe Hyaluronic Acid Injections.

Medical Prior Authorization

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

Claims

• NavigateECHO Health Enrollment Form – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Overpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.

• Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
• NavigateItemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.

Appeals

• NavigateProvider Appeal Request Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
• Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.

Fraud, Waste and Abuse

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