Provider Forms and Resources

Documents and Forms Library

Claims and Reimbursement Forms

Wheelchair Request Form
To request the initial purchase and delivery of a wheelchair and accessories.

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). 

Health Care Administrative Solutions (HCAS) Provider Enrollment Form
Standardized Provider Information Change Form. 

Medical Authorizations

Prior Authorization Request Form
To request authorization on services.

• Outpatient Form
• Inpatient Form

Prior Authorization Policy - Effective until 12/31/24
Prior Authorization Policy - Effective 01/01/2025
The general information and code list for the Prior Authorization Request Form.

Appeal Request Form
To request reconsideration of denial of medical coverage or payment.

2024 Stars Measure 
Find the requirements and exclusions.

Pharmacy Benefits

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.

Formulary Drug List
Learn more about the Mass Advantage Formulary of covered drugs.

Part D Drugs Requiring Authorization
To view the list of medications requiring authorization before use.

Part D Drugs Requiring Step Therapy
To view requirements before authorization of certain drugs.