Forms and Documents

Questions? Contact Customer Services (808) 532-4000, or toll free 1 (800) 458-4600 8 a.m. - 5 p.m. Hawaii Standard Time Monday through Friday except holidays

Provider Forms

Advance Financial Notice

PDF Document

Claim Reconsideration Request (Provider Claims Action Request Form)

PDF Document

Concurrent Care Physician Brochure

PDF Document

Drugs that Require Prior Authorization

PDF Document

How To Initiate An Appeal

PDF Document

Express Scripts National Preferred Formulary and Exclusions List

PDF Document

ICD-10 Facts

PDF Document

Letter to Providers RE: OOS Services for Members

PDF Document

Medical Payment Policies

Link

Medical Travel Checklist for Out of State Care

PDF Document

Long Term Opioid Therapy Consent and Medication Agreement

PDF Document

Online Provider Services – new account

Online Form

Online Participating Provider Add Form

Online Form

Online Participating Provider URL Add Form

Online Form

Online Participating Provider Change Form

Online Form

Online Participating Provider Service Location Form

Online Form

Online Timely Claim Filing Waiver Form

Online Form

Non-Formulary Drug Coverage Request Form

PDF Document

Prior Authorization Tool for Medical Services

Link

Prior Authorization Tool for Prescription Drugs

Link

Procedures That Are Considered Cosmetic

PDF Document

Provider Handbook

PDF Document

W-9

PDF Document

Services That Require Prior Authorization

PDF Document

Vaccination Fee Review Request Form

PDF Document

Login to Online Provider Services and use the Forms tab at the top of the Welcome Page to access these forms:

Authorization for Electronic Funds Transfer (EFT) Provider Form

Link

Online Provider Services – new user

Link

EDI

Electronic Claim Submission (EDI)

Link

Electronic Trading Partner Agreement

PDF Document

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