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). 

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 and Code List - Effective 07/01/2025
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.