Forms & Documents

Appeals
PDF iconAppeal Form (Please note: The appeal form should not be used to submit a claim correction or as a venue for submitting medical records or EOBs.)

Claims Processing

Professional Claim Adjustment 
PDF iconDownload

Institutional Claim Adjustment
PDF iconDownload

PDF iconMedical Records Submission Form
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
Please note: Submit through the Availity portal on the Authorizations and Referrals page

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
PDF iconProvider Directory Maintenance Form - Please complete if you received a letter requesting updates.
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 provider portal to view member eligibility, check claim status and more.
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