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

Medical and Behavioral Health Submissions: For all Medical and Behavioral Health services, please refer to the Innovista portal to determine authorization requirements and submit a request form. For all Pharmacy requests, please log into the Provider Portal to check authorization requirements or submit a faxed request to 888-871-0564 using the forms provided below.

Appeals & Grievances

Provider Waiver of Liability (WOL) Statement

Authorizations

Medical Admission Fax Cover Sheet

State-Specific Authorization Forms

Claims

Refund Check Information Sheet* (RCIS)

Medical Records

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

This policy provides a list of drugs that require step therapy. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

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: 8/27/2021