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 1-833-230-2101.
• 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.
• Navigate Provider Debarment Form – Use this form to provide attestation of provider information.
• Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.

Member-Related Forms

• Navigate PCP Change Request Form – Members may submit this form to request a change in primary care provider (PCP).
• Care Management Referral Form – This form can be submitted using the Provider Portal.
• Navigate Interpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
• Navigate Coordination of Care and Release of Information Form – Use this form to share patient care information with another provider. Please note the release of information clause at the end of page 2.
• Life Services Referral Form – CareSource Life Services^® is a program that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer a patient to this program.

Pharmacy Prior Authorization

• Ohio Department of Medicaid (ODM) Pharmacy Prior Authorization Forms – Visit the ODM Prior Authorization (PA) Information page or the Single Pharmacy Benefit Manger (SPBM) website at https://spbm.medicaid.ohio.gov/ for prior authorization forms for prescription drugs and products covered through the SPBM, Gainwell Technologies.
• Covered outpatient provider administered drugs that are dispensed by a pharmacy are reviewed and reimbursed by the SPBM pursuant to Ohio Administrative Code (OAC) 5160-26-13 managed health care programs claim billing for pharmaceuticals.
• Navigate Medical Provider Administered Drugs Prior Authorization Form – Submit this form to request prior authorization to prescribe provider administered drugs covered and reimbursable by CareSource. Please see the Pharmacy page for more information.
• Navigate Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
• 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.
• Navigate 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.
• Nursing Facility Form – Submit this form to request prior authorization for a nursing facility admission
• Home Health Care Services Prior Authorization Form – Submit this form to request prior authorization for home health care services.
• Navigate 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.
• Navigate SUD 1115 Waiver Universal Prior Authorization Form – Submit the SUD 1115 Waiver Universal PA Form to request prior authorization for residential and partial hospitalization Substance Use Disorder (SUD) services.

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

Appeals

• Navigate Provider Appeal Request Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue. This form can be submitted using the Provider Portal (preferred submission method).
• 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.