Medicare Assured Forms & Reference Materials

Gateway Health is now Highmark Wholecare! Click here to visit our new website. We will continue to provide health care to serve the whole you.
You can find out how this partnership will impact you here.

Medicare Assured Provider Manual
Provider Manual

NIA Reference Material
NIA Reference Material

Medicare Assured Provider Forms and Reference Material
PHARMACY FORMS
CMS Standardized Part D Hospice Information Drug Request Form
Home Infusion Drug Request Form
Medicare Drug Exception Form
Oncology and Supportive Therapy Request Form Submit requests via Navinet.
BEHAVIORAL HEALTH AUTHORIZATION REQUEST FORMS
Discharge Form
Inpatient Authorization Request Form
Inpatient Substance Use Authorization Request Form
Outpatient Authorization Request Form
GENERAL PROVIDER FORMS & REFERENCES
After Hours Services
Appointment of Representative Form
Annual Wellness Visit Tools and Reference Materials
Care for Older Adults (COA) Form
Cataract Removal Questionnaire
Clinical Services Referral Guide
CMS-1500 Form
CMS UB-04 Form
Consent to Release Health Information to Coordinate Physical and Behavioral Health Care
Cultural Competency Data Form
Electronic Funds Transfer (EFT) Authorization Agreement Form
How to Use the Provider Portal Search Tool
ICD-10 Submitter-Provider Quick Start Guide
In-Service Materials
Late Notification FAQ - Medicare
Living Will Declaration
Mass Claims Adjustment Coding Guide
Mass Claims Adjustment Tip Sheet
Maternity Outcomes Authorization Form
Medicare Outpatient Observation Attestation
Medicare Outpatient Observation Notice
Medicare Outpatient Observation Notice Instructions
Member Outreach Form
Model of Care
NaviNet Phase 2
Non-Participating Provider Complaint Form
Obstetrical Needs Assessment Form (ONAF)
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Optum OB User Guide
Outpatient Program Exceptions Request – Please submit via Navinet.
Practice/Provider Change Request Form
Prior Authorization Requirements (PA)
Provider Self-Audit Overpayments Form
Refund Form
Waiver of Liability Statement Form
W-9 Form

Medicare Assured Forms & Reference Materials

Need Help Finding a Policy?