Forms

Below, you’ll find essential forms and documents providers need to best serve our members.

Note: You may need to download Adobe Acrobat Reader to open these files.

Practice Changes

• Provider Education Attestation Form
  Use this form to provide an attestation of completing education requirements.
• Provider Maintenance Form
  Use the Provider Portal to alert us to changes in your practice. To locate this form, log in to the portal and select “Provider Maintenance” from the navigation bar.

Pharmacy Prior Authorization Forms

• Navigate Pharmacy Prior Authorization Request Form
  Request prior authorization for pharmacy benefit medications.
• Navigate Pharmacy Operations Specialty Prior Authorization Request Form
  Request prior authorization for specialty medications, including physician-administered medications.
  
• Navigate Pharmacy Operations Facility Change Request Form
  Request a change to the servicing provider for an existing physician-administered medication authorization.
  
• Navigate Compound Prior Authorization Form
  Request prior authorization for multi-ingredient compound medications.
  

Medical Prior Authorization Forms

• Navigate Marketplace Provider Medical Prior Authorization Request Form
  Request Prior Authorization for a medical service or treatment.

Claims

• Navigate Itemized Bill Cover Sheet
• Navigate Overpayment Recovery Form

Disputes & Appeals Forms

• Navigate Appointment of Representative to File an Appeal on Patient/Member's Behalf
  Get permission from the member to file an appeal on their behalf.
• Navigate Standard Appeal Form
  Request an appeal for an authorization, post-service, contract or other issue.
• Navigate Expedited Appeal Form
  If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided.

Fraud, Waste and Abuse Form

• Fraud, Waste and Abuse Online Reporting
  Use this online form to report suspected fraud, waste or abuse.