Provider Forms

Case Management

• Case Management Referral Form
• Certificate of Medical Necessity — Blank
• Certificate of Medical Necessity — TENS

Claims

• Request for Claim Review Form and Instructions (This form is not to be used for Level of Care Request for Review.)
• Medicare Preventive Services Educational Tool 
• Provider Remit Appeal Review Rights
• Non-Plan Provider Appeal & Waiver of Liability Statement Form
• Electronic Payment and Remittance Enrollment (This form is for providers who submit claims electronically. Please complete a separate form for each office location.)
• Medical Director Form
• Skilled Nursing Facility Immunization Billing

Compliance

• FDR Attestation Form
• FDR Offshore Subcontractor Attestation

Network Providers

• Provider Information Change Form
• Provider Request for Termination Form

Prescription Drugs

• Request for Medicare Prescription Drug Coverage Determination. Use this form to request a coverage determination or exception to our drug formulary.
• Request for Redetermination of Medicare Prescription Drug Denial. Use this form to file an appeal related to a member's Part D prescription drug benefits.
• Part D Authorization Information

Utilization Management

• Hospital Admission Notification form
• Request for Review of IP Status

Prior Authorization

• Prior Authorization Request Form
• Inpatient Rehabilitation and Long Term Acute Care (IPRH)
• Power Mobility Device Questionnaire (Must be completed in addition to Prior Authorization Request Form.)

Skilled Nursing Facilities

• Request to Discontinue Skilled Services
• SNF Admission Notification form
• SNF Update form

This page was last updated 07/22/2024