Provider Forms

• Authorization for Automatic Bank Deposit Form (pdf): Fill out this form to have insurance payments directly deposited into your clinic/business bank account.
• Electronic Remittance Advice (835) Request Form (pdf): An electronic remittance advice (ERA) is an explanation from the health plan to a provider about a claim payment. Use this form to request to receive these forms through eProvider Solutions.
• Request for Reconsideration (Word): Submit this form to request that a denied claim be reconsidered for reimbursement.
• Request to Appoint a Provider (pdf): This form signed by patient/member and provider to appoint the provider to pursue appeals of full or partial payment on the patient/member’s behalf.
• Home Phototherapy Order Form (pdf): This physician’s written order for home phototherapy is needed for health insurance approval of this treatment.
• Pre-Determination Request (pdf): A request made by the provider to the health insurance company to determine how much of a billed amount would be covered. This is an estimate and does not guarantee benefits or payment of services.

Forms for Clinical Review

• Autoimmune Drug Specific Preauthorization (pdf)
• Chemotherapy Preauthorization (pdf)
• Drug Preauthorization Request (pdf)
• Inpatient Admission Notification (pdf)
• Outpatient Preauthorization Request (pdf)
• Durable Medical Equipment Preauthorization Request (pdf)
• Multiple Sclerosis Drug Specific Preauthorization (pdf)
• Request for Drug Formulary Exception (pdf): Request a review for coverage of a drug that is not covered on a drug formulary.

Member Information

Additional preauthorization forms are located within the member-specific preauthorization page. Providers will need a member ID card to identify the group number to access.