Forms
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Member-Related Forms
- NavigateCoordination 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.
- NavigatePCP Change Request Form – Members/providers may submit this form to request a change in primary care provider (PCP).
- NavigateProvider Initiated Dismissal Form – Submit this form to request a primary medical provider (PMP) initiated member reassignment to another PMP.
Pharmacy Prior Authorization
- NavigatePharmacy Prior Authorization Form – Submit this form to request a prior authorization for a medication to be processed under the pharmacy benefit.
- NavigateSpecialty 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
- NavigateMedical 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.
- NavigateClaim Refund Check Form – Mail your refund check, this form and any other required documentation to HAP CareSource.
- NavigateOverpayment Recovery Form – Submit this form to offset overpaid claims against a future payment.
- NavigateItemized Bill Cover Sheet – Submit this cover sheet and itemized statement for high dollar claims.
- NavigateAHS Consent Forms Instruction
- NavigateClaims Dispute Form
Appeals
- NavigateProvider Appeal Form – Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.
- NavigateExpedited Appeal Form – Submit this form to request an expedited appeal for a claim denial or a medical necessity/utilization management decision.
- NavigateConsent for Provider to File an Appeal on Patient/Member's Behalf – Submit this form to request an appeal on behalf of a member.
