Forms and Documents
Benefit Plans
For Large Groups (51 or more employees)
For Small Groups (50 or less employees)
Provider Forms
- Advance Financial Notice
- Authorization for Electronic Funds Transfer (EFT) Provider Form
- Claim Filing Waiver Form
- Claim Reconsideration Request
(Provider Claims Action Request Form) - Concurrent Care Physician Brochure
- How To Initiate An Appeal
- ICD-10 Facts
- Medical Payment Policies
- Online Provider Services - new account
- Online Provider Services - new user
- Participating Provider Add Form
- Participating Provider Change Form
- Pediatric Health Screening Checklist
- Preferred Drug Listing
- Preferred Drug List (condensed)
- Prior Authorization for Medical Services
- Prior Authorization for Prescription Drugs
- Procedures That Are Considered Cosmetic
- Provider Handbook
- Services that Require Prior Authorization
- Vaccination Fee Review Request Form
- W-9
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