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

• Appeal Request Form - Member
• Appeal Request Form - Provider
• Appointment of Representative Form
• Grievance Form - Member
• Transfer of Member - PCP Request Form
   

Authorizations

• Ancillary Authorization Form
• Care Management Referral Form
• Certification of Abortion
• Consent to Hysterectomy
• Consent to Sterilization
• Inpatient Authorization Form
• Newborn Birth Notification Form 
• Outpatient Authorization Form
• Prenatal Notification Form
   

Behavioral Health

• Behavioral Health Treatment Plan Update Form

Claims

• CMS 1500 Guidelines for Paper Claims
• CMS 1500 Submission Sample
• Outbound Benefit Enrollment Companion Guide
• Dental Claims / Encounter Guide
• Institutional Claims / Encounter Guide
• Professional Claims / Encounter Guide
• UB-04 Guidelines for Paper Claims
• UB-04 Submission Sample
• Electronic Data Interchange Job Aid
   

"How To" Guides

• Filing an Authorization-Related Claim Appeal
• Filing a Claim Appeal
• How to Request an Authorization
• How to Become a Registered Web User
• How to Check the Status of a Claim Online
• How to Submit an Outpatient Authorization Request Online
• How to Verify Eligibility
• OB Hospital Services- Authorization and Notification Requirements
• Pharmacy Services Guide
• Prenatal Notification and High-Risk OB Program
• Provider Self-Service Options
• Tips on How to File Claims
• Web Capabilities
• What is HEDIS^®?
   

Medical Records

• Adult New Member Physical Form
• Child Check-up Forms
• Immunization Record
• Incident Report
• Medication Profile
• OB Stroller Program Form
• Problem List
   

Pharmacy Services

• Accu-Chek Meter Form
• Abbott Monitor Form  
• Enteral Nutritional Supplement Form
• Injectable-Infusion Prior Authorization Form
• Prior Authorization Request Form
• Synagis Order Form
   

Quick Reference

• Quick Reference Guide
• Quick Reference Guide - No Authorization Required CPT Code List

 

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