Provider Forms and Resources

Claims and Reimbursement Forms

Provider Request for Claim Review Form (Contracted)
To request review of a claim that has been denied or updated.

Provider Request for Claim Review Form (Non-Contracted)
To request review of a claim that has been denied or updated. This form is for non-contracted providers.

Waiver of Liability
To receive liability waver from enrollees.

Appointment of Representative Form
Would you like someone to request an appeal for you? You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative.

Electronic Funds Transfer (EFT) Agreement
To transfer funds electronically. 

W-9 Form
Form W-9 to provide your correct Taxpayer Identification Number (TIN). 

Standardized Provider Information Change Form

Health Care Administrative Solutions (HCAS) Provider Enrollment Form

Medical Authorizations

Prior Authorization Request Form
To request authorization on services.

• Outpatient Form
• Inpatient Form

Prior Authorization Policy and Code List - Effective 01/01/2026
The general information and code list for the Prior Authorization Request Form.

Provider Appeal Request Form - Pre-Service ONLY
To request reconsideration of denial of medical coverage or payment.

Pharmacy Benefits

Formulary Drug List
To review the list of covered drugs and any restrictions they may have.

• Basic (HMO), Plus (HMO), or Premiere (PPO) Plans
• Extra (PPO) Plan 

Coverage Determinations, Appeals and Grievances Information
Learn about coverage and ways to appeal coverage denial.

Coverage Determination Printable Form
To request medical prescription drug coverage.

Redetermination/Appeal Form
To request redetermination of Medicare prescription drug denial.

Other

2026 Stars Measure Descriptions and Codes

Prior Authorization Metrics

To comply with the CMS Interoperability and Prior Authorization Final Rule, Mass Advantage is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (for example, approvals and denials) over the previous calendar year.

Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, these metrics may be used to compare plans, programs, and payers.

Prior Authorization Decision Timeframes

Prior to January 1, 2026, Medicare Advantage plans and applicable integrated plans are required to issue prior authorization decisions within the following timeframes:

• 72 hours for expedited (urgent) requests
• 14 calendar days for standard (non-urgent) requests

Beginning January 1, 2026, the CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage plans to issue prior authorization decisions within:

• 72 hours for expedited (urgent) requests
• 7 calendar days for standard (non-urgent) requests

Reporting Period: 2025

Medical Services Requiring Prior Authorization (Excluding Drugs)

Prior Authorization Metrics Report