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.
Forms to Update Your Information
Coordination of Healthcare Exchange of Information Form Use this form to exchange information between health care providers and coordinate care on behalf of members. | This form is used for members to consent to sharing health information with health care providers |
Provider Education Attestation Form Use this form to provide attestation of completing education requirements. | Organizational Provider Credentialing Application Form Use this form to supply demographic, certification and billing information and submit the form along with your New Health Partner Contract Form. |
Use this form to provide attestation of provider information and submit it along with your New Health Partner Contract Form. | 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. If you are unable to access the Provider Portal, please contact your Health Partner Engagement Specialist for assistance. |
Use this spreadsheet to list all provider information for rendering providers. | Use this form to provide your Taxpayer Identification Number (TIN) and certification information. Please submit this form along with your New Health Partner Contract Form. |
Claims-Related Forms
Submit this form if you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information. | Submit this form to enroll with ECHO Health, our electronic funds transfer partner. |
Non-Participating Provider Profile Form Providers who are not in the CareSource network must complete the Non-Participating Provider Profile Form in order to submit claims. After we receive your profile, you will receive credentials to log in to the Provider Portal, where you can submit claims electronically. The form can be located on our Claims page. | Providers must exhaust the claim dispute process as outlined above before filing a claim appeal. Claim appeals must be submitted:
Claims appeals filed without first submitting a dispute will not be processed. Arbitration Process: If you are dissatisfied with the decision of the claim appeal, you may submit the matter to binding arbitration. The binding arbitration process must be conducted in accordance with the rules and regulations of the American Health Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act as adopted in the State of Indiana at IC-34-57-2-2. |
Member-Related Forms
Coordination of Healthcare Exchange of Information Form Use this form to exchange information between health care providers and coordinate care on behalf of members. | This form is used for members to consent to sharing health information with health care providers |
Interpreter Service Request Form Submit this form to request interpretation services for an upcoming appointment for a CareSource member. | 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. |
For additional information about medically frail referrals and determination, access the FAQ document. | Use this form to make a referral for medically frail determination. |
Medical Prior Authorization Form Submit this form to request prior authorization for a medical procedure. | Please complete the Member Reassignment Form if you would like to remove a patient from your panel. |
Submit this form to request primary medical provider (PMP) assignment for a member’s baby prior to birth. | Substance Use Disorder Quality Improvement Project Case Management Referral Form Submit this form to engage members admitted to the emergency department with substance use disorder (SUD) in case management. |