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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.
- Update Your Information – Please submit any changes for your practice using the Provider Maintenance Form on the Provider Portal. Simply login to the Portal and select “Provider Maintenance” from the navigation area on the left-hand side of the page.
- Provider Debarment Form – Use this form to provide attestation of provider information.
- 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.
- 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.
- 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.
- CMS 1500 Health Insurance Claim Form – Waiver services providers who cannot log into the Provider Portal can use this form to submit a claim. You can access Instructions to complete the form and a list of valid service codes.
- 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 – Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.
- 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.
- Appointment of Representation (AOR) form – Submit this form if you are not a physician or a physician representative.
- 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.
- CareSource TMD Screening Examination Form – Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.
Fraud, Waste and Abuse
- Fraud, Waste and Abuse Reporting Form – Submit this form to report suspected fraud, waste or abuse.
- Utilization Management Prior Authorization Form Submit this form to request prior authorization from Utilization Management for medical services (such as inpatient admission or home health care), or for durable medical equipment.