Reference Materials

• 2023 Provider and Billing Manual (PDF)
  
• 2022 Provider and Billing Manual (PDF)
  
• 2021 Provider and Billing Manual (PDF)
• Member Notification of Pregnancy (PDF)
• Notification of Pregnancy Form (PDF)
• Well-Being Survey (PDF)
• Prior Authorization Request Form for Prescription Drugs (PDF)
• ICD-10 Information
  
• Practice Guidelines (PDF)
  
• No Surprises Act Open Negotiation Form (PDF)
  
• Diabetes Care Form (PDF)
• Prenatal and Postpartum Care (PDF)
• Women’s Care Form (PDF)
• Well-Care Visits Form (PDF)
• Annual Care for Older Adults (COA) Form (PDF)

Medical Management/ Behavioral Health

• Inpatient Authorization Form (PDF)
  
• Outpatient Authorization Form (PDF)
  
• Clinical Policy: Brand Name Override and Non-Formulary Medications (PDF)
• Biopharmacy Outpatient Prior Authorization Fax Form (PDF)
• Provider Request for Reconsideration and Claim Dispute Form (PDF)
• Prior Authorization Request Form for Non-Specialty Drugs (PDF)