Forms
Behavioral Health
- 10-Day Adverse Event Conference Form - English (PDF)
- Adverse Event Report Immediate Notification - English (PDF)
- Level 5 Referral Form - English (PDF)
- Assessment, Screening and Monitoring Tool for Pediatric Members Prescribed an Atypical Antipsychotic Medication - English (PDF)
- BH Case Management Authorization for Representative Payee - English (PDF)
- BH Case Management Authorization for Supported Employment and Peer Support - English (PDF)
- BH Case Management Authorization Request for Supportive Housing - English (PDF)
- BH Case Management Status Change Notification - English (PDF)
- Inpatient Admission Notification and Followup - English (PDF)
- Intensive Outpatient Treatment IOP Authorization - English (PDF)
- Licensed Crisis Residential Shelter Authorization - English (PDF)
- Psychosocial Rehab Authorization Request - English (PDF)
- Serious Mental Illness 1157 Application Form - English (PDF)
- Serious Mental Illness SMI 1157 Instructions - English (PDF)
- Specialized Residential Treatment SRT Authorization - English (PDF)
- Steps for Root Cause Analysis - English (PDF)
Claims
- CMS 1500 Submission Sample - English (PDF)
- Dental Claims Encounter Guide - English (PDF) (Coming Soon)
- Encounter Reference Guide - English (PDF) (Coming Soon)
- Institutional Claims Encounter Guide - English (PDF)
- Outbound Benefit Enrollment Companion Guide - English (PDF)
- Professional Claims Encounter Guide - English (PDF)
- Reimbursement Policies - English (PDF) (Coming Soon)
- Taxonomy Guide - English (PDF)
- UB-04 Submission Sample - English (PDF)
Pharmacy
- Coverage Determination - English (PDF)
- Injectable Infusion Prior Authorization - English (PDF)
- Medication Appeal Request - English (PDF)
Other Forms
- Authorization to Exchange Confidential Information - English (PDF)
- Disclosure of Ownership and Control Interest Statement - English (PDF)
- Medical Necessity of Mode of Transportation Certification - English (PDF)
- Telemedicine Authorization Request Form - English (PDF)
- Website Registration Large Group IPAs - English (PDF)