Document Library

For your convenience, we have compiled the most frequently used documents in one location. This collection of files and forms is available to you from our health plans. Here you will find our provider manual, pre-certification requirements, and other supporting documentation to help you provide superior service to our members. For formulary information, please visit our pharmacy section. If you wish, you may view, print, or store these files below for your future reference.

Provider Notification: Eviti Connect

March 2020 - EVV Provider Notification: Personal, respite and companion care services require Electronic Visit Verification

Quick Reference Guide

Provider Notification- Span Billing

Personal and respite care services require Electronic Visit Verification

Network Relations Consultant contact list

MCO Authorization Processes

Important Tip for Opening Forms

CCC+ Registration Form

Beh Therapy Initial SRA

CMHRS and Beh Therapy Continued Stay

Day Tx PHP Rehab Services Initial

EPSDT Beh Therapy Initial SRA

ICT Rehab Services SRA

IIH Rehab Services Initial SRA

MHSS Rehab Services Initial SRA

PSR Services Initial SRA

TDT Rehab Services Initial SRA

CIR Revised

Residential Treatment Services Manual Cover Memo

Residential Treatment Services Chapter 2 (updated 6-30-17)

Residential Treatment Services Chapter 4 (updated 6-30-17)

Residential Treatment Services Chapter 6 (updated 6-30-17)

 

ERA Enrollment Form

Ted E. Bear M.D. Incentive Flyer

ARTS Extension Service Authorization Request Form

ARTS Initial Service Authorization Request Form

ARTS Substance Use Case Management Registration Form

Behavioral Therapy Initial Authorization Request Form

CMHRS & Behavioral Therapy Continued Stay Service Authorization Request Form

Day Treatment Partial Hospitalization (H0035 HB) Initial Service Authorization Request Form

Intensive Community Treatment (H0039) Initial Service Authorization Request Form

Intensive In-Home (H2012) Initial Service Authorization Request Form

Mental Health Skill-Building (H0046) Initial Service Authorization Request Form

Psychosocial Rehabilitation (H2017) Initial Service Authorization Request Form

Service Registration Form

Therapeutic Day Treatment (H0035-HA) Initial Service Authorization Request Form

CCC Plus Wellness Rewards Flyer

Diabetes Wellness Exam Flyer

Maternity Incentive Program Form

Well Woman Flyer

Prenatal Risk Assessment Form

Prenatal Risk Assessment Form Provider Incentive Flyer

EFT form

Provider Dispute and Resubmission Form

Prior authorization form