Provider Forms

Claims | Clinical/UM | COVID-19 Forms | Network Mgt | POMS | Provider Relations | Quality Mgt

Claims Dept Forms

• Claims Batch Header Form
• CMS-1500 Claim Form
• NPI Notification Letter
• NPI Submission Form – Individual Practitioner
• NPI Submission Form – Organizational Provider
• Online Services Account Request Form
• Online Account Request Form – Access for Multiple Providers
• Online Services Intermediary Authorization Form
• Timely Filing Waiver Request Form
• UB-04 Claim Form

Clinical / Utilization Management Forms

Authorization Forms

• ACT CTT Continued Stay Request
• ACT CTT Pre-Certification Request
• Acute Partial Hospitalization (APH) Auth Request Form
• Adult Non-Acute Partial Hospitalization Pre-Cert Authorization Request
• Adult Non-Acute Partial Hospitalization Continued Stay Authorization Request
• Authorization Request Form for ASAM 1.0
• Authorization Request Form for ASAM 2.1
• Authorization Request Form for ASAM 2.5
• Case Conceptualization Tool (Greene, Fayette and Beaver Counties only)
• Child/Adolescent Partial Hospitalization Pre-Cert Authorization Request
• Child/Adolescent Partial Hospitalization Continued Stay Authorization Request
• Child/Adolescent School-Based Partial Hospitalization Pre-Cert Authorization Request
• Child/Adolescent School-Based Partial Hospitalization Continued Stay Authorization Request
• Fayette County Forensic Diversion Recovery Program (FDRP) Auth Request Form
• HLOC Substance Use Authorization Request Form – Pre-Cert
• HLOC Substance Use Authorization Request Form – Continued Stay 
• LTSR Continued Stay Request
• LTSR Pre-Certification Request
• Medication Management Form
• Methadone Maintenance Precert
• Methadone Maintenance Continued Stay Review
• Methadone Maintenance Discharge
• Preferred and Prior Preferred Psychological Registration Form
• Psych Rehab Pre-Cert Form
• Psych Rehab Continued Stay Request
• Psychological Evaluation Request (PER) Form
  • List of Psychological Tests
• ProviderConnect RFS Form
• Retro-Authorization Form
• RTF Request for Hold Bed Days

Family Based Mental Health Services

• Family Based Review Process Instructions
• FBMHS Recommendation
• Family Based Review Precert Form
• Family Based Mental Health Services 16 Week Review Form
• Family Based Mental Health Services 24 Week Review Form
• Family Based Mental Health Services Booster Registration Form
• Family Based Review Discharge Form
• How to Request Family Based Services Authorizations via ProviderConnect

Medicare Primary Insurance Forms

• Medicare Primary Insurance Notification ITR
• Medicare Primary Insurance DC Form

Outpatient Review Form

• Mental Health Intensive Outpatient Precert
• Mental Health Intensive Outpatient Auth Request (CSR)
• Mobile Medications Precert
• Mobile Medications CSR
• ORF Instructions
• Outpatient Psych ORF

Other Forms

• Grievance Release Form
• Integrated Care Release of Information
• Medical Exception Request Worksheet Form
• PCIT Fidelity Tool
• RTF Discharge Form

COVID-19 Temporary Registration Forms

• COVID-19 – ACT-CTT Registration
• COVID-19 – IP MH Registration
• COVID-19 – MDF and TI1 Service Classes Registration
• COVID-19 – MH IOP Registration
• COVID-19 – Mobile Medications Registration
• COVID-19 – PHP Registration
• COVID-19 – Primary Insurance Registration for Inpatient Mental Health
• COVID-19 – Psych Rehab Registration
• COVID-19 – SUD PHP Registration
• COVID-19 – SUD IOP Registration
• COVID-19 – FDRP Registration
• COVID-19 – ICM Registration
• COVID-19 – Family Based Registration

Network Management Forms

• For ALL Provider Updates/Change of Address
• W-9 Substitute Form

POMS Forms

HealthChoices POMS

• POMS: Submit Online via ProviderConnect
• DHS Instructions – POMS

Provider Relations Forms

• Rate Review Request Form

Quality Management Forms

• Table of Incidents
• Critical Incident Log
• Critical Incident – Code 255.5 Clarification
• Critical Incident Reporting PowerPoint