Please use the links on this page to download forms and pertinent information.
To view a member's Copayment Summary or Evidence of Coverage document, please use the eligibility tool.
- Advantage Referral Handbook
- BH Coordination of Care Flyer
- BH Summary of Care Form
- Clinical Provider Handbook
- CM Semi Annual Data Reporting Template
- CM Referral Form
- Disease Management Form
- Mom's Meals Referral Form (Medicare)
- P&T Conflict of Interest Disclosure Statement
- Preferred Drug List: EHB
- Preferred Drug List: FEHB
- Preferred Drug List: Premium
- Preferred Drug List: Premium + Infertility
- Prior Authorization Request Form
- Provider Dispute Resolution Request Spreadsheet
- Provider Dispute Resolution Request
- Provider Manual
- Medicare Provider Waiver of Liability
- Medicare Non-Contracted Provider Appeal Rights
- UM CCM File Summary
- UM CCM Manager Contact List
- UM CCM Program Effectiveness Measures
- UM CCM Work Group Minutes
- UM Document Submissions
- UM Plan Group Minutes
- UM P&P Concurrent Review
- UM CM/CCM Audit Checklist
- UM IRR Audit Form
- UM P&P Medical Benefit Policy Interpretation Inquiry
- UM Prior Authorization and Benefits
- UM Program Description
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