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.
• Health Partner Change Request Form – Submit this form to alert CareSource to a change within your practice.

Member-Related Forms

• PCP Change Request Form
  – Members may submit this form to request a change in primary care provider (PCP).

• 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.

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 hepatitis 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.
• NavigateHyaluronic Acid Injections Prior Authorization Form – Submit this form to request prior authorization to prescribe Hyaluronic Acid Injections.

Medical and Other 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.

Claims

• InstaMed Order Form – Payer Payments – Submit this form to enroll in InstaMed, 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.
• NavigateItemized 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.
• 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.

Dental

• ODJFS Dental Services Prior Authorization Form – Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.
• ADA Dental Claim Form Instructions – Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.
• Dental EFT Enrollment Authorization Agreement Form – Follow the instructions to enroll in Scion Dental’s EFT program.
• Orthodontic Evaluation and Predetermination Form – Submit this form to request prior authorization for orthodontic services.
• Orthodontic Continuation of Care Form – Submit this form to request continuation of care for orthodontic services.
• Orthodontic Confirmation of Care Form – Submit this form to notify CareSource that a referred patient is not a candidate for comprehensive orthodontic treatment.
• Orthodontic Treatment Plan Acknowledgment Form for Comprehensive Orthodontic Treatment – Submit this form along with a prior authorization request to acknowledge a comprehensive treatment plan for a dental patient.
• Evaluation Form for Comprehensive Orthodontic Treatment – Use this form to evaluate a patient for comprehensive orthodontic treatment options.
• Orthodontic Form for Non-Compliance/Termination with Comprehensive or Interceptive Orthodontic Treatment – Submit this form to notify CareSource of a patient’s noncompliance/termination during orthodontic treatment.
• CareSource TMD Screening Examination Form – Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.

Pregnancy 

• Breast Pump Prescription Form – Submit this form to prescribe a breast pump for a CareSource Medicaid member.
• Prenatal Risk Assessment Form – Submit this form to document a pregnancy risk assessment screening.
• Edinburgh Postnatal Depression Scale (EPDS) – Use this form to identify patients at risk for perinatal depression.

Abortion, Hysterectomy and Sterilization 

Forms

• ODM Abortion Certification Form – Submit this form to certify that the service meets the Ohio Department of Medicaid’s criteria to receive Medicaid reimbursement.
• ODJFS Acknowledgement of Hysterectomy Information – Submit this form to document acknowledgment that a patient received hysterectomy information prior to the procedure(s), in compliance with Ohio Department of Job and Family Services (ODJFS) requirements.
• ODJFS Consent for Sterilization Form – Submit this form to certify a patient received sterilization information and gave consent prior to the procedure(s), in compliance with ODJFS requirements.

Instructions 

• Guidelines for Completing the Sterilization Form – Follow the instructions to complete the U.S. Department of Health and Human Services (HHS) Consent for Sterilization from and become eligible to receive CareSource reimbursement for the service.
• Consent for Sterilization Sample Form – Refer to this form as a sample of the Consent for Sterilization form.
• Guidelines for Completing the ODJFS Hysterectomy Form – Follow the instructions to complete the ODJFS Acknowledgement of Hysterectomy Information form and become eligible to receive CareSource reimbursement for the service.
• Acknowledgement of Hysterectomy Sample Form – Refer to this form as a sample of an Acknowledgement of Hysterectomy Information form.

Fraud, Waste and Abuse

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