Forms

Find the form you need for appeals, claims, prior authorizations, and other common tasks.

Find a form

Here you'll find a wide variety of our most frequently used forms. Forms are in Adobe (.pdf) format. Don't have Adobe Reader? Get it here.

If you can't find the form you need, please contact us.

Select the plan type from the tabs below for forms and information.

Individual plans Group plans

Prior authorization

Prior authorization request form - Individual plans only use one prior authorization request form for all services including DME and provider-administered infusion drugs.

Claims, billing, appeals

Provider appeal submission form with authorization – Member authorization is embedded in the form for providers submitting on a member's behalf. See section C.
Corrected claim cover sheet – Correct billing information on a previously processed claim.
Policy reconsideration form – Request reconsideration of a coding policy
Standard provider letter for refunds under $50 - Use this form to document refunds under $50. (We don't send letters requesting a refund for overpayment of less than $50 per claim).
Supporting documentation cover sheet - Submit supporting documentation required to process a claim.
Overpayment notification form – General instructions for providers

Credentialing and updates

See the Join Our Network page for credentialing forms and information.

Visit our Update Provider Information page for resources to update your provider information and directory listing.

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

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

Letter for refunds less than $50 - We don't send a letter requesting a refund for overpayments of less than $50 per claim. Use this form for your documentation purposes.