Provider : Forms

This page is a repository of forms and documents listed by function. The information is intended for use by Providers and Hospitals. Documents related to Member Services are included for your reference. If you have any questions, please contact our Provider Hotline at 1 (800) 951-7719.

Administrative Review

Authorizations

• Ancillary Authorization Form
• Care Management Referral Form
• Certification of Abortion
• Consent to Hysterectomy
• Consent to Sterilization
• Federal Sterilization Form HHS-687
• Federal Sterilization Form HHS-687-1 Spanish
• Inpatient Authorization Form
• Newborn Birth Notification Form
• Outpatient Authorization Form
• Prenatal Notification Form
• OH CareCore National Frequently Asked Questions for Providers

 

Claims

• CMS 1500 Submission Sample
• Outbound Benefit Enrollment Companion Guide
• Dental Claims / Encounter Guide
• Institutional Claims / Encounter Guide
• Professional Claims / Encounter Guide
• UB-04 Submission Sample
• NDC Reporting Guidelines
• Taxonomy Guide 

 

Provider Job Aids and Resource Guides

• Ohio Medicaid Provider Resource Guide 
• Ohio Medicaid Provider How-To Guide 
• How to Submit a Global OB/GYN Authorization Request Online
• Quick Access Guide to Provider Services
• OB Hospital Services- Authorization and Notification Requirements
• Prenatal Notification and High-Risk OB Program
• What is HEDIS^®?

 

Medical Records

• Adult New Member Physical Form
• Child Check-up Forms
• Immunization Record
• Incident Report
• Medication Profile
• Prenatal Reward Visits Log Form
• Problem List

 

Pharmacy Services

• Enteral Nutritional Supplement Form
• Injectable-Infusion Prior Authorization Form
• Medication Appeal Request Form
• Direct Member Reimbursement Form
• Synagis Order Form
• Appointment of Representative Form
• Coverage Determination Request Form

 

Quick Reference

• Quick Reference Guide

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Last modified: 01/25/2012