Forms & Documents

Claims Processing

Professional Claim Adjustment 
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Submit Electronically

Institutional Claim Adjustment
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Submit Electronically

PDF iconMedical Records Cover Sheet
PDF iconCOB Questionnaire
PDF iconRequest for Independent External Review
PDF iconAdvance Member Notice
PDF iconWorkers Compensation / No Fault / Subrogation
PDF iconWorkers Compensation / No Fault / Subrogation - Dakotas Health Plan
PDF iconWorkers Compensation / No Fault / Subrogation - FEP

Comprehensive Orthodontic Treatment Plan
PDF iconComprehensive Orthodontic Treatment Plan Form

Healthy Steps
PDF iconHealthy Steps Referral for Out of State Services

New Technology
PDF iconTechnology Assessment Evaluation Criteria

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

PDF iconInsulin Prior Approval
PDF iconDispensing Limit Override
PDF iconOpioids Dispensing Limit Override
PDF iconCoverage Exception
PDF iconProvider Request for Contraceptive Coverage
PDF iconReimbursement for Provider Dispensed Take Home Drugs
PDF iconStep Therapy
PDF iconCOX-2 Inhibitor Step Therapy
PDF iconGlucose Test Strip Prior Approval
PDF iconMigraine Step Therapy
PDF iconNSAID/GI Protectant Step Therapy

PDF iconStatin Step Therapy
PDF IconPatient Protection and Affordable Care Act (PPACA) Preventive Copay Waiver Form - If your benefit plan is subject to PPACA preventive services, you may request a Copay Waiver for a product within a preventive service class that is not a designated preventive service product.

PDF iconAlternate Care Preauthorization (Home Health, Skilled Nursing Facility, Transitional Care Unit, Hospice, Acute Rehab, Long Term Acute Care)
PDF iconInpatient Medical/Surgical Preauthorization

Prior Approval - see pharmacy section above for forms to request an override to a dispensing limit, insulin prior approval or step therapy requirement
PDF iconPredetermination Request Form
PDF iconAPDS, CGM, Insulin Pump Supplement

Psychiatric/Substance Abuse
PDF iconPrior Authorization for ABA services for Autism Spectrum disorder
PDF iconInpatient Psychiatric and Substance Abuse Admission

PDF iconExtension of Physical Therapy Window

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