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.

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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 Education Attestation Form
  Use this form to provide attestation of completing education requirements.
• 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.

Member-Related Forms

• Navigate Coordination of Care and Release of Information Form
• Navigate Primary Care Provider (PCP) Change Request Form

Pharmacy Prior Authorization

Please Note: Effective July 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

• Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to CareSource.
• ECHO Health Enrollment
  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
• Overpayment Recovery Form 
  Providers may submit Recovery Requests via the Provider Portal.
• 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 Appointment of Representative to File an Appeal on Patient/Member's Behalf 
  Submit this form to request an appeal on behalf of a member.
• Navigate Standard Appeal Form
  Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
• Navigate 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.

Fraud, Waste and Abuse

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