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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 1-844-679-7865.
- Health Partner Change Request Form – Submit this form to alert CareSource to a change within your practice.
Medical Prior Authorization
- Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure.
- 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.
- Waiver of Liability Form for Claim 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.
CareSource is an HMO with a Medicare contract. Enrollment in CareSource Advantage Zero Premium™ (HMO), CareSource Advantage® (HMO), and CareSource Advantage Plus™ (HMO) depends on contract renewal.