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.
• NavigateProvider Debarment Form – Use this form to provide attestation of provider information.

Member-Related Forms

• NavigatePCP Change Request Form – Members may submit this form to request a change in primary care provider (PCP).
• NavigateBreast Pump Request Form – Submit this form to request a breast pump for a CareSource Medicaid member.
• Care Management Referral Form – This form can be submitted using the Provider Portal.
• Life Services Provider Referral Form – Submit this form to refer a CareSource member to the CareSource Life Services program.
• NavigateInterpreter Service Request Form – Submit this form to request interpretation services for an upcoming appointment for a CareSource member.
• NavigateCoordination 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.

Pharmacy Prior Authorization

• NavigatePharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource Medicaid NavigatePreferred 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.
• NavigateHepatitis C Treatment Prior Authorization Form – Submit this form to request prior authorization for hepatits C treatment.
• NavigateSpecialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the CareSource Medicaid PDL.
• NavigateSynagis 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.
• NavigateExtended Release Opioid Prior Authorization Form – Submit this form to request prior authorization to prescribe extended release opioids that exceed daily, dose, or quantity limits.
• NavigateCompound 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

• NavigateMedical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure. 
• NavigateOhio 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.
• NavigateOhio 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.
• NavigateSUD 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.
• 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. This form can be submitted using the Provider Portal (preferred submission method).
• NavigateConsent 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.