...you and the person that you appoint must complete the Appointment of Representative form. Return the completed form to us along with your grievance, appeal, or request for an external...

...Urine Drug Screening Prior Authorization Form – Submit this form when requesting prior authorization for urine drug screenings Submit the SUD 1115 Waiver Universal PA Form to request prior authorization...

...regarding CareSource’s member rights and responsibility policy How can I get information sent to me in paper form? You can request information be sent to you in paper form. This...

...button. CareSource now uses Indiana Medicaid’s Statewide Uniform Preferred Drug List (SUPDL), over-the-counter (OTC) drug list, supplements and contraception formularies. The SUPDL and related criteria can be found on the...

...easily locate all the forms you may need for your CareSource Medicare Advantage plan. Visit the Forms page to find any form when you need it. Prior Authorization List Some...

...This includes providers that perform in-office surgeries. These services should be available at no cost to the member. Submit the Interpreter Service Request Form (coming soon) to request interpretation services...

...West Virginia Health Coverage Programs and CareSource require that you submit your National Provider Identifier (NPI) number to CareSource along withthe completed West Virginia uniform credentialing and recredentialing form.Also complete...

...by completing this form. Coverage Redetermination Request Form – If you are unsatisfied with the outcome of a coverage determination request, you can file an appeal using the redetermination form....

...drug your provider initially prescribed. Notice of Formulary Changes (Last Updated 04/01/2026) If changes occur to drugs on our Part D formulary, we will update them in this list. Preferred...

...that involve your protected data. Medical and Administrative Appeals: Humana – CareSource at times may make decisions about claims for services provided to you. You or your provider may appeal...