Forms & Resources

Below are important forms and information:

• Hospice form
• Provider Pharmacy Coverage Determination Form
• Prior Authorization List
• Prior Authorization Form
• Waiver of Liability Statement
• Electronic Remittance Advice (ERA) Form
• Electronic Funds Transfer (EFT) Form
• Model of Care Training
• Par Provider Dispute Form
• Non-Par Provider Appeal Form
• Getting Started in ConnectCenter
• 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

Instructions on disputing Provider claims online can be found here.