Provider forms

Appeals

Provider appeal submission with authorization - Resolve billing issues that directly impact payment or a write-off amount. Note the different fax numbers for clinical vs. general appeals. Member authorization is embedded in the form for providers submitting on a member's behalf (section C).

Policy reconsideration - Request reconsideration of a coding policy.

Processing or correcting claims 

Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed claim. For more details, see corrected, replacement, voided, and secondary claims in Electronic Funds and Claims.

Support document cover sheet - Submit medical records or other required supporting documentation to process a claim.

Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident.

Other coverage questionnaire - Provide information about a patient's other healthcare coverage.

Billing

Balance billing protection act dispute – Providers or facilities not contracted with LifeWise can submit a balance billing dispute request. The form must be received by LifeWise within 30 days from receipt of the original payment notification. Find out more about the Balance Billing Protection Act.

Overpayment notification - Notify us of an overpayment your office received.

Letter for refunds less than $25 - We don't send a letter requesting a refund for overpayments of less than $25 per claim. Use this form for your documentation purposes.

Care management 

Admission notification and discharge notification

Prior authorization and pre-approval 

General prior authorization request

Out-of-network exception request - Request in-network benefits for an out-of-network service.

Durable medical equipment (DME)

Infusion drugs

Emergencies and extenuating circumstances policy

We know situations can happen that may make it impossible to get prior authorization before treating a patient, or to notify us within 24 hours of admission. If a patient’s emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.

In these situations, contact us before submitting a claim. Follow the recommended practices outlined in the extenuating circumstances policy so that the claim isn't automatically denied.

Pharmacy 

Pharmacy exception request form

Pharmacy prior authorization request fax form

Credentials & updates

View our practitioner credentialing checklist and the Join Our Network page for more information.

Facility credentialing and provider updates

Organization/facility credentialing/recredentialing application - To join our provider network as a facility, complete this application and a W-9 form. Email us your completed documents. The credentialing process typically takes 30 days. Acceptance is based on your application information and network requirements. If your submitted application is accepted, you'll receive a contract to review and sign. Once you return your signed contract, you’ll receive a counter-signed contract and the effective date of your participation.

Updating provider information: Visit our Update Provider Info page for information and resources to keep your provider directory data current.