Documents and Forms
Medical Referrals & Authorizations
- 2022 Prior Authorization list
- 2022 Part B Drug List
- 2022 IL Prior Authorization Fax Submission Forms - Inpatient (PDF)
- 2022 IL Prior Authorization Fax Submission Forms - Outpatient (PDF)
- Authorization Referral Information
- 2020 MeridianComplete Authorization Lookup (PDF)
- Behavioral Health Discharge Transition of Care Form (PDF)
- HealthHelp and eviCore Provider Notification (PDF)
- Weight Watchers® Form (PDF)
- Primary Care Provider Reassignment Form (PDF)
Pharmacy
Mandatory Training Attestation (PDF)
Preventive Care (HEDIS®) (PDF)
- Annual Care for Older Adults (COA) Form (PDF)
- Breast Cancer Screening Exclusion Form (PDF)
- Colorectal Cancer Screening Exclusion Form (PDF)
- Diabetes Exclusion Form (PDF)
- Glaucoma Screening Exclusion Form (PDF)
- HEDIS® Criteria (PDF)
Adverse Events
Billing
- Timely Submission of Encounter Data by Medicare-Medicaid Plans (MMPs) to CMS (PDF)
- Prohibition Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (PDF)
- Request for Provider Dispute Form