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.

Provider Letter Attachment

*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)

EFT form

ERA form

PAR Provider Dispute form

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)

Health Risk Assessment form

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

Keying Institutional Claims in ConnectCenter

Obtaining a Claim status in ConnectCenter

Provider Roster