Forms

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

Note: You may need to download Adobe Acrobat Reader to open these files.

Contracting, Credentialing and Practice Changes Forms

• Navigate CareSource PASSE Common Roster Template
  This form should be completed by large facilities needing to add a large number of providers. Providers may attach the completed form to their New Health Partner Contracting Form application, or email the form to us if they’ve already filled out an application.
• Navigate CCVS Provider Authorization and Release Form
  Submit this form to authorize release of credentialing information to CareSource PASSE.
• Navigate Debarment Form
  Use this form to provide ownership of disclosure information.
• Navigate HCBS Credentialing Application
  This form should be completed by HCBS providers to be credentialed with CareSource PASSE.
• New Health Partner Contract Form
  Submit this form if you are interested in becoming a CareSource PASSE™ provider. Need help? Refer to the Navigate Becoming a Health Partner Step-by-Step Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2100.
• Navigate Organizational Credentialing Application
  This form should be completed by organization/facility for credentialing.
• Navigate Provider Attestation Form
  Submit this form to attest to practice competency prior to working with CareSource PASSE.
• Provider Change Request Form (coming soon)
  Submit this form to alert CareSource PASSE to report a change within your practice.
• Provider Education Attestation Form
  Use this form to provide attestation of completing education requirements.
• Provider Maintenance Form
  Use the Provider Portal to alert CareSource PASSE to changes in your practice. Log in to the portal and select “Provider Maintenance” from the navigation.

Incident Reporting Form

• Navigate Incident Report Form
  To report incidents, HCBS and PRTF providers should utilize the DHS DDS Incident Reporting Portal online, if they have access to the Portal. If a provider does not have access to the online Portal, the Navigate Arkansas PASSE Incident Report Form should be completed and emailed to CareSource PASSE and to DHS.

Member-Related Forms

• Navigate Independent Reassessment Dates Form
  Submit this form to request a member’s Independent Reassessment dates.
• Navigate Interpreter Service Request Form
  Submit this form to request interpretation services for an upcoming appointment for a CareSource members.

Pharmacy Prior Authorization Forms

• Navigate Hepatitis C Virus (HCV) Medication Therapy Request Sheet
  Submit this form to request prior authorization for hepatitis C treatment.
• Navigate H.P. Acthar® Gel (Corticotropin Injection) Infantile Spasm Prior Authorization Request Form
• Navigate Medication Informed Consent Document for Behavioral or Psychiatric Conditions Clients < 18 years of Age
  A newly signed and dated form by all parties is required for changes in antipsychotic chemical entity or delivery system.
• Navigate Pharmacy Prior Authorization Request Form
  Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource PASSE member’s Preferred Drug List (PDL).
• Navigate Specialty Pharmacy Prior Authorization Request Form
  Submit this form to request prior authorization to prescribe specialty pharmacy medications.
• Navigate Statement of Medical Necessity Information Form for INGREZZA® (valbenazine) or AUSTEDO® (deutetrabenazine)
  Submit this form to request prior authorization to prescribe Ingrezza (valbenazine) or Austedo (deutetrabenazine).
• Navigate Statement of Medical Necessity for Adult Use of a C-II stimulant
  Submit this form to request prior authorization to prescribe a C-II stimulant for patients 19 years of age or older with attention-deficit/hyperactivity disorder (ADD/ADHD).
• Navigate Statement of Medical Necessity for Xolair® (Omalizumab)
  Submit this form to request prior authorization to prescribe Xolair (Omalizumab).
• Navigate Sublocade® (buprenorphine SQ Injection) VIVITROL® (naltrexone ER IM injection) Statement of Medical Necessity
  Submit this form to request prior authorization to prescribe Vivitrol.
• Navigate Synagis® Prior Authorization Form
  Submit this form to request prior authorization to prescribe Synagis.

Prior Authorization Forms for Medical, Waiver, and Other Services

Prior Authorizations forms for medical, waiver, and other services can be found on the Prior Authorization page.

Claims Forms

• Navigate Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to CareSource PASSE.
• ECHO Health Enrollment
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims
• Navigate Overpayment Recovery Form
  Submit this form to offset overpaid claims against a future payment.
• Navigate Pharmacy Paper Claims Form
  Submit this to Express Scripts^® (ESI) using the instructions on the form.
• Navigate Provider Standard Claim Dispute Form
  Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.

Appeals Forms

• Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf
  Submit this form to request an appeal on behalf of a member.
• Navigate Provider Appeal Form
  Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.

Fraud, Waste and Abuse Form

• Navigate Fraud, Waste and Abuse Reporting Form
  Submit this form to report suspected fraud, waste or abuse.