Forms & Documents

Claims Processing

Professional Claim Adjustment 
Download
Submit Electronically

Institutional Claim Adjustment
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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

Healthy Steps
Healthy Steps Referral for Out of State Services

New Technology
Technology Assessment Evaluation Criteria

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

Pharmacy
Provider Request for Contraceptive Coverage   (Submit Electronically)
Reimbursement for Provider Dispensed Take Home Drugs
Statin Step Therapy
Step Therapy

Preauthorization
Inpatient Acute Medical/Surgical Admission Notification

Prior Approval
Prior Approval Request

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

Therapy
Extension of Physical Therapy Window

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