Forms

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Contracting and Practice Changes

• New Health Partner Contract Form – Submit this form if you are interested in becoming a CareSource^® provider. This form can also be used to change your tax ID number, as well as add products. Need help? Refer to the User’s Guide for Completing New Health Partner Contract Form. 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.
• Provider Education Attestation Form – Use this form to provide attestation of completing education requirements.

Member-Related Forms

• Navigate PCP Change Request Form
• Navigate Coordination of Care and Release of Information Form

Pharmacy Prior Authorization

Please Note: Effective 7/1/2024, in accordance with West Virginia Senate Bill 267, all prior authorization requests must be submitted electronically via the CareSource Provider Portal.

Medical Prior Authorization

• Navigate Medical Prior Authorization Form – Submit this form to request prior authorization for a medical procedure.

Claims

• 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.
• Claim Refund Check Form – Mail your refund check, this form and any other required documentation to CareSource.
• Navigate Itemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
• 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.

Disputes & Appeals

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

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