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.
- Provider Debarment Form – Use this form to provide attestation of provider information.
Member-Related Forms
- PCP Change Request Form – Members may submit this form to request a change in primary care provider (PCP).
- Breast Pump Request Form – Submit this form to request a breast pump for a CareSource Medicaid member.
- Care Management Referral Form – Submit this form to refer a CareSource member for care management services.
- 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.
- Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
Pharmacy Prior Authorization
- Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource Medicaid Preferred Drug List (PDL).
- Ohio Medicaid Universal Managed Care Prior Authorization Form – Submit this universal Ohio Medicaid managed care form to request prior authorization to prescribe medications.
- Hepatitis C Treatment Prior Authorization Form – Submit this form to request prior authorization for hepatits C treatment.
- Specialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the CareSource Medicaid PDL.
- Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
- Medication-Assisted Treatment (Buprenorphine Products) Prior Authorization Form – Submit this form to request prior authorization to prescribe buprenorphine and buprenorphine-containing medications.
- Immediate Release Opioid Prior Authorization Form – Submit this form to request prior authorization to prescribe immediate release opioids that exceed daily, dose, or quantity limits.
- Extended Release Opioid Prior Authorization Form – Submit this form to request prior authorization to prescribe extended release opioids that exceed daily, dose, or quantity limits.
- 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.
Medical Prior Authorization
- Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure.
- Ohio Association of Health Plans Universal Outpatient Behavioral Health Prior Authorization Form – Submit this universal Ohio Association of Health Plans form to request prior authorization for outpatient behavioral health services.
- Home Health Care Services Prior Authorization Form – Submit this form to request prior authorization for home health care services.
- Ohio Urine Drug Screen Prior Authorization Form – Submit this form to request prior authorization for urine drug screening for Ohio Medicaid patients with a substance use disorder.
Claims
- ECHO 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.
- Nonparticipating Provider Profile Form – Submit this form with a nonparticipating provider’s claim.
- Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
- Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
Appeals
- Provider Appeal Request Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
- 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.