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 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