Forms
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- New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource® provider. Need help? Refer to thr Step-by-Step Join Our Network Guide. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2101.
- Provider Maintenance Form – Use the Provider Portal to alert CareSource to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.
- PCP Change Request Form
- Life Services Referral Form – CareSource Life Services® is a program that provides non-medical support that can include assistance with housing, food insecurity and employment. Use this form to refer a patient to this program.
- Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe certain medications, as outlined in the CareSource Formulary.
- Specialty Pharmacy Prior Authorization Form – Submit this form to request prior authorization to prescribe specialty pharmacy medications, as outlined in the Formulary.
- Synagis Prior Authorization Form – Submit this form to request prior authorization to prescribe Synagis.
- Compound Prior Authorization Form – Submit this form to request prior authorization to prescribe compounds.
- Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure. This form should be submitted using the Provider Portal.
- ECHO Health Enrollment – Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
- Overpayment Recovery Form – Providers may submit Recovery Requests via the Provider Portal.
- Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
- 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.
- Standard Appeal Form – Submit this form to request an appeal for an authorization, post-service, contract or other issue.
- Expedited Appeal Form – If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided.
- Appointment of Representative to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.
- Fraud, Waste and Abuse Reporting Form – Submit this form to report suspected fraud, waste or abuse.