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Medicare Providers

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Forms

Access key forms for authorizations, claims, pharmacy and more.

Appeals & Grievances

Authorizations

This request will be treated as per the standard organization determination time frames.

Drug Prior Authorization Requests Supplied by the Physician/Facility

Behavioral Health Forms

Illinois Behavioral Health Forms


This document includes Harmony and WellCare covered services and authorization guidelines for Community Mental Health Center (CMHC) Services.

This document includes Harmony and WellCare covered services and authorization guidelines for Division of Alcoholism and Substance Abuse (DASA) Services.

Harmony/WellCare IET referral (Engagement Appointment)

Harmony/WellCare IET referral (Initial Appointment)

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Other Provider Forms

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Last Updated On: 2/7/2020