Forms & Documents

Appeals
PDF iconAppeal Form

Claims Processing

Professional Claim Adjustment 
PDF iconDownload
Submit Electronically through THOR (Please note: For claims processed in the legacy system only, i.e. date of service prior to a member's migration to the new platform)

Institutional Claim Adjustment
PDF iconDownload
Submit Electronically through THOR (Please note: For claims processed in the legacy system only, i.e. date of service prior to a member's migration to the new platform)

PDF iconMedical Records Cover Sheet
PDF iconCOB Questionnaire
PDF iconRequest for Independent External Review
PDF iconAdvance Member Notice
PDF iconAdvance Member Notice - Migrated Members (members migrated to new claims processing system) 
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

Authorized Referral
PDF iconAuthorized ReferralUse for network-based products including Healthy Steps

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

Pharmacy
Retail Pharmacy Forms

PDF iconCoverage Exception
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.

Precertification
PDF iconInpatient Authorization Request
PDF iconOutpatient Authorization Request

PDF iconAPDS, CGM, Insulin Pump Supplement – This form is to accompany the appropriate authorization request
PDF iconABA Service for Autism Spectrum Disorder Request Form

Self-service through Availity

Availity is the new provider portal to view member eligibility, check claim status and more. 
Availity login button