Forms

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• HAP CareSource Provider Change Form
  Use this form for changes to existing provider information.

Member-Related Forms

• Navigate Coordination of Healthcare Exchange of Information Form
  Behavioral health providers should use this form when referring members to primary care and other health services to promote safe and effective coordination of care.
• Navigate PCP Change Request Form
  Members/providers may submit this form to request a change in primary care provider (PCP).
• Navigate Provider Initiated Dismissal Form
  Submit this form to request a primary medical provider (PMP) initiated member reassignment to another PMP.

Pharmacy Prior Authorization

• Navigate Change in Facility Request Form
  Complete and submit this form to request a facility change. Applicable to medical benefit only.
• Navigate Pharmacy Prior Authorization Form
  Submit this form to request a prior authorization for a medication to be processed under the pharmacy benefit.
• Navigate Specialty Pharmacy Prior Authorization Request Form
  Submit this form to request a prior authorization for a specialty medication to be processed under the pharmacy benefit OR a physician administered drug to be processed under the medical benefit

Medical and Other Prior Authorization

• Navigate Medical Prior Authorization Request Form
  Submit this form to request prior authorization for a medical or behavioral health service.

Claims

• ECHO Health Enrollment
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to HAP CareSource.
• Navigate Overpayment Recovery Form
  Submit this form to offset overpaid claims against a future payment.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
• Navigate AHS Consent Forms Instruction
• Navigate Claims Dispute Form

Appeals

• Navigate Provider Appeal Form
  Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
• Navigate Expedited Appeal Form
  Submit this form to request an expedited appeal for a claim denial or a medical necessity/utilization management decision.
• 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.

Facility and Medical Record Standards

• Facility Standards for Practitioners and Providers
• Medical Record Standards for Practitioners and Providers