Claims and EDI Forms (In-Network Providers)
- W9
- Claim Adjustment Form
- Provider Refund Form
- Claims Research Request Template
- Addiction and Recovery Treatment Services (ARTS)
Claims and EDI Forms (Out-of-Network Providers)
Contracting
Medical Management
- Alere Referral
- DME Request Form
- ESPDT Medical Needs Assessment
- Newborn Notification Form
- OB Registration Form
- Outpatient and Inpatient Procedure/Service Request Form
- Botox Injection (Type A) - Xeomin (Medical)
- Botox Injection (Type A) - Chronic Migraine (Medical)
- Botox Injection (Type A) - Hyperhidrosis (Medical)
- Botox Injection (Type A) - Upper Limb & Lower Limb Spasticity (Medical)
- Feraheme|Inectafer|Monoferri (Medical)
- Gonadotropin-releasing Hormone Agonists (GnRH) (Medical)
- Infliximab IV (Preferred: Inflectra) (Non-Preferred: Avsola|Infleximab|Remicade|Reflexis) (Medical)
- IVIG - Primary Immune Deficiency (PID) (Medical)
- IVIG - SQ PID (Gammagard|Gammunex-C|Hizentra|Hyqvia|Cuvitru (Medical)
- IVIG (for Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)) (Medical)
- Macular Degeneration Drugs IV (Medical)
- Nulojix (Medical)
- Ocrevus (Medical)
- Orencia-Graft Versus Host Disease (GVHD (Medical)
- Orencia IV (Infusion) (Medical)