Medicare Advantage Provider Forms

Join or Update Network Information

Credentialing

Uniform Practitioner Credentialing Application (PDF)
Uniform Facility Credentialing Application (PDF)

Update/ Manage your Information

Uniform Practitioner Add-Change Form (PDF)
Non-credentialed Practitioner Add Form (PDF)
Non-credentialed Practitioner Change Form (PDF)
Non-credentialed Practitioner Terminate Form (PDF)
Location Add Form (PDF)
Location Demographic/Update Form (PDF)
Location Close Form (PDF)
Provider Notification Change/Update/Termination Third-Party Agreement (PDF)

Prior Authorizations, Notifications and Referrals 

Medical

DME / Supply Prior Authorization Request Form (PDF)
General Prior Authorization Request Form (PDF)
Prior Authorization Genetic Testing Form (PDF)
Hospice Election Communications Form (PDF)
Pre-Determination Request Form (PDF)
Nursing Home/ Swing Bed Admission Notification

Mental Health / Substance Use Disorder

Prior Authorization – Mental Health Outpatient Services (PDF)
Substance Use Disorder (SUD) Outpatient Services (PDF)
Prior Authorization for Out-of-Network Mental Health & Substance Use Disorder Services (PDF)
Notification of Inpatient Mental Health Admission (PDF)
Notification of Inpatient Substance Use Disorder (PDF)
Release of Information Form (PDF)

Referrals

Disease Management Referral Form  (PDF)
Care Management Referral Form (PDF)

Claims and Billing

Provider Claim Reconsideration Request Form (PDF)
Health Care Claim Attachment Cover Sheet (PDF)
Gender Identity Information Form (PDF)
Waiver of Liability Statement (PDF)
Provider Notification Change/ Update/ Termination Third-Party Agreement (PDF)

PHARMACY

For all provider-related pharmacy forms, including prior authorizations for medical injectable drugs, please visit the pharmacy page

Denials

Notice of Medicare Non-coverage (Advance Notice) (NOMC)
NOMNC Valid Delivery Documentation Form (PDF)
Detailed Explanation of Non-Coverage Form (DENC) 
NDMCP – Notice of Denial of Medical Coverage (NDMC)

Medical Necessity Criteria

Medical Necessity Criteria Request Form (PDF)