Forms & Documents

Claims Processing

Professional Claim Adjustment 
Submit Electronically

Institutional Claim Adjustment
Submit Electronically

Medical Records Cover Sheet
COB Questionnaire
Request for Independent External Review
Advance Member Notice
Workers Compensation / No Fault / Subrogation
Workers Compensation / No Fault / Subrogation - Dakotas Health Plan
Workers Compensation / No Fault / Subrogation - FEP

Comprehensive Orthodontic Treatment Plan
Comprehensive Orthodontic Treatment Plan Form

Healthy Steps
Healthy Steps Referral for Out of State Services

New Technology
Technology Assessment Evaluation Criteria

Participation & Credentialing
Accepting New Patients Update Form
Application to Become a Participating Provider
Submit change of Tax ID
Update Provider Information
EFT Payment Information
Secure Area Assurance - Medical Records Fax Requests

Insulin Prior Approval
Dispensing Limit Override
Opioids Dispensing Limit Override
Coverage Exception
Provider Request for Contraceptive Coverage
Reimbursement for Provider Dispensed Take Home Drugs
Step Therapy
COX-2 Inhibitor Step Therapy
Glucose Test Strip Prior Approval
Migraine Step Therapy
NSAID/GI Protectant Step Therapy

Statin Step Therapy

Inpatient Acute Medical/Surgical Admission Notification

Prior Approval - see pharmacy section above for forms to request an override to a dispensing limit, insulin prior approval or step therapy requirement
Predetermination Request Form

Psychiatric/Substance Abuse
Outpatient Psychiatric and Substance Abuse Documentation of Medical Necessity
Out of State Providers — Inpatient Psychiatric and Substance Abuse Admission

Extension of Physical Therapy Window

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