Forms & Resources
You’ll find many of the forms you need on this website. However, to make things easier for you, we’ve gathered a few of them together in one place. See below for some of the most common forms and important information as you work with us.
Joint Electronic Funds Transfer and Electronic Remittance Advice Signup
*NEW* Prior Authorization Form
Provider Letter - New Prior Authorization Form
Waiver of Liability (WOL) form
CMS 1500 form
Prior Authorization forms (Medicare-Medicaid)
Prior Authorization forms (Medicaid)
Non-PAR Provider Appeal form (Medicaid)
Non-PAR Provider Appeal form (Medicare-Medicaid)
Coverage determination online (Medicare-Medicaid Plan Pharmacy)
Provider Pharmacy Coverage Determination form (Medicare-Medicaid Plan Pharmacy) (updated 4/14/2021)
Coverage redetermination online (Medicare-Medicaid Plan Pharmacy)
Coverage redetermination form (Medicare-Medicaid Plan Pharmacy)
Compliance Program Guidelines Provider Attestation
Getting Started in Connect Center
Getting Started with Eligibility in ConnectCenter
Getting Started with Provider Management in ConnectCenter
Getting Started with Claims in ConnectCenter
Uploading a Claim in ConnectCenter
Keying Professional Claims in ConnectCenter