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Provider Forms & Reference Materials

Medical Assistance (Medicaid) Forms    Medicare AssuredSM Forms

Medical Assistance (Medicaid)

Provider Forms & Reference Materials

PHARMACY FORMS

Medicaid Drug Exception Form

Six Prescription Benefit Limit Exception Request Form

GENERAL PROVIDER FORMS & REFERENCES
Adjustment Code Crosswalk

Annual Wellness Visit Tools and Reference Materials

Asthma Action Plan
Benefit Limit Exception (6 Script Limit)
Benefit Limit Exception Provider Education - Presentation
Certification for Expedited Review Form
Chlamydia Testing Consent
Clearinghouse/Vendor Trading Partner Agreement

CMS UB04 Form

CMS-1500 Form

Electronic Billing Companion Document
EPSDT Billing Document
Electronic Funds Transfer (EFT) Authorization Agreement Form
FAQ's for Credentialing
Family Planning and Obstetrical Needs Quick Reference Guide
Lead Screening Analysis Form

Living Will Declaration

MA30 - Hysterectomy English

MA30 - Hysterectomy Spanish

MA31 - Sterilization Form - English

MA31 - Sterilization Form - Spanish

MA300X - Medical Assistance Provider Order Forms for Providers

Maternity Outcome Authorization Form

Member Benefit Packages / Co-Pay Matrix

Member Outreach Form

Neonatal Abstinence Syndrome
New Trading Partner Application
NPI Billing Reference Guide

OB/GYN Referral Form

Obstetrical Needs Assessment Form (OBNAF)

On Call PCP Care Coverage Agreement 

On Call Specialty Care Coverage Agreement 

Patient Question List

Practice/Provider Change Request Form 

Private Duty Nursing Handbook
Provider Trading Partner Agreement

Referral Form

Refund Form
Sample Capitation Reports
Structured Screening for Developmental Delays and Autism Spectrum Disorders
TCM Tools and Reference Material
Voiance Interpreter Services
W9 - Form W-9 Request for Taxpayer ID Number and Certification

Medicare AssuredSM

Provider Forms & Reference Materials

PHARMACY FORMS
Home Infusion Drug Request Form

Medicare AssuredSM Drug Exception Form

Medicare Part D Coverage Determination Request Form
Pharmacy NCPDP Payer Sheet
Synagis Prescription and Prior Authorization Request Form
GENERAL PROVIDER FORMS & REFERENCES
Appointment of Representative Form

CMS-1500 Form

CMS UB-04 Form

Clearinghouse/Vendor Trading Partner Agreement

Electronic Funds Transfer (EFT) Authorization Agreement Form
FAQ's for Credentialing

Living Will Declaration

Maternity Outcomes Authorization Form
Member Outreach Form
New Trading Partner Application
Non-Par Provider Payment Dispute 
Notice of Medicare Non-Coverage Form
Notice of Medicare Non-Coverage Form (Spanish)

Obstetrical Needs Assessment Form

Patient Question List
PCP On Call Coverage Arrangement Form
Practice Change Request Form
Provider Trading Partner Agreement
Quick Reference Guide for Authorizatons
Refund Form
Summary of Benefits Pennsylvania Medicare Assured DiamondSM (HMO SNP) and Medicare Assured RubySM (HMO SNP)
Summary of Benefits Pennsylvania Medicare Assured GoldSM (HMO SNP) and Medicare Assured PlatinumSM (HMO SNP)
Summary of Benefits Ohio Medicare Assured DiamondSM (HMO SNP) and Medicare Assured RubySM (HMO SNP)
Summary of Benefits Ohio Medicare Assured GoldSM (HMO SNP) and Medicare Assured PlatinumSM (HMO SNP)
Summary of Benefits Ohio Medicare Assured ChoiceSM (HMO SNP) and Medicare Assured PrimeSM (HMO SNP)
TCM Tools and Reference Material
Voiance Interpreter Services
Waiver of Liability Statement Form

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