秋葵app

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

You may need to download to open these files.

Contracting and Practice Changes Forms

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  Submit this form if you are interested in becoming a 秋葵app^® provider. Need help? Refer to the User’s Guide for Completing New Health Partner Contract Form. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2101.
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  Use this form to provide attestation of completing education requirements.
• Provider Maintenance Form
  Use the Provider Portal to alert 秋葵app to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.

Member-Related Forms

• Navigate Coordination of Care and Release of Information Form
  Use this form to share patient care information with another provider. Please note the release of information clause at the end of page 2.
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  秋葵app Life Services^® is a program that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer a patient to this program.
• Navigate PCP Change Request Form
  Members may submit this form to request a change in primary care provider (PCP).

Pharmacy Prior Authorization Forms

• Navigate Pharmacy Prior Authorization Form
  Submit this form to request a prior authorization for coverage of certain medications, as outlined in the 秋葵app Formulary.
• Navigate Specialty Pharmacy Prior Authorization Form
  Submit this form to request a prior authorization for coverage of certain specialty medications, as outlined in the 秋葵app Formulary, or to request coverage of medications to be administered by a physician in an outpatient setting under the medical benefit.

Medical Prior Authorization Form

• Navigate Medical Prior Authorization Form
  Submit this form to request prior authorization for a medical procedure.

Claims Forms

• Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to 秋葵app.
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  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
• Overpayment Recovery Form
  Providers may submit Recovery Requests via the Provider Portal.
• Navigate Provider Standard Claim Dispute Form
  Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.

Disputes & Appeals Forms

• Navigate Appointment of Representative to File an Appeal on Patient/Member's Behalf
  Submit this form to request an appeal on behalf of a member.
• Navigate Standard Appeal Form
  Submit this form to 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

• Navigate Fraud, Waste and Abuse Reporting Form
  Submit this form to report suspected fraud, waste or abuse.