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Forms and Practice Support
FORMS AND PRACTICE SUPPORT
Appeals and Dispute Forms
Contracted Providers
- Contracted Post Service Appeal and Claim Dispute Form [PDF]
- Contracted Post Service Appeal and Claim Dispute Form - Arizona Providers [PDF]
Non Contracted Providers
Network Interest Forms - Facility/Ancillary
- Alabama, North Florida, and Southern Mississippi [PDF]
- Arkansas [PDF]
- Colorado, New Mexico, Oregon, Utah, and Washington [PDF]
- Connecticut [PDF]
- Delaware, Maryland, New Jersey, Pennsylvania, Virginia, and Washington DC [PDF]
- Florida - Central [PDF]
- Florida - South [PDF]
- Georgia [PDF]
- Illinois [PDF]
- Kansas City [PDF]
- North Carolina and South Carolina [PDF]
- Ohio [PDF]
- Oklahoma and Texas [PDF]
- St. Louis [PDF]
- Tennessee [PDF]
- Vermont [PDF]
Network Interest Forms - Practitioner
- Alabama, North Florida, and Southern Mississippi [PDF]
- Arkansas [PDF]
- Colorado, New Mexico, Oregon, Utah, and Washington [PDF]
- Connecticut [PDF]
- Delaware, Maryland, New Jersey, Pennsylvania, Virginia, and Washington DC [PDF]
- Florida - Central [PDF]
- Florida - South [PDF]
- Georgia [PDF]
- Illinois [PDF]
- Kansas City [PDF]
- North Carolina and South Carolina [PDF]
- Ohio [PDF]
- St. Louis [PDF]
- Tennessee [PDF]
- Texas [PDF]
- Vermont [PDF]
Part B Drugs/Biologics
2022
Drugs/Biologics Part B Step Therapy Quick Reference Guides
- Part B Step Therapy Quick Reference Guide [PDF] Effective 1/1/2022 Updated 12/2021
Drugs/Biologics Part B Precertification Forms
- Drugs/Biologics Part B Precertification Form [PDF]
- Durable Medical Equipment (DME) Diabetic Testing Supplies Request [PDF]
Drugs/Biologics Part B Step Therapy Precertification Forms
- Avastin [PDF]
- Herceptin [PDF]
- Neupogen and Granix [PDF]
- Remicade [PDF]
- Rituxan [PDF]
- Udenyca Fulphila [PDF]
- Viscosupplement [PDF]
2021
Drugs/Biologics Part B Step Therapy Quick Reference Guides
- Part B Step Therapy Quick Reference Guide [PDF] Effective 1/7/2021-12/31/2021
- Part B Step Therapy Quick Reference Guide [PDF] (AZ Only)
Drugs/Biologics Part B Precertification Forms
- Drugs/Biologics Part B Precertification Form [PDF]
- Drugs/Biologics Part B Precertification Form [PDF] (AZ Only)
- Durable Medical Equipment (DME) Diabetic Testing Supplies Request [PDF]
- Durable Medical Equipment (DME) Diabetic Testing Supplies Request [PDF] (AZ Only)
Drugs/Biologics Part B Step Therapy Precertification Forms
- Avastin [PDF]
- Avastin [PDF] (AZ Only)
- Nivestym-Neupogen [PDF] (AZ Only)
- Herceptin [PDF]
- Herceptin [PDF] (AZ Only)
- Neupogen and Granix [PDF]
- Remicade [PDF]
- Remicade [PDF] (AZ Only)
- Rituxan [PDF]
- Rituxan [PDF] (AZ Only)
- Udenyca Fulphila [PDF]
- Visco [PDF]
- Visco [PDF] (AZ Only)
Practice Support
- 360 Annual Wellness Exam [PDF] UPDATED 1/2022
- Access and Availability Survey Standards – Medical Providers [PDF]
- Behavioral Health
- Cigna Medicare ID Cards [PDF]
- Clinical Practice Guidelines – 2021 [PDF]
- Patient Support Programs
- Physician Notice to Discharge Customer from Panel Form [PDF]
- Provider Directory
- Provider Online Portal – Claimstat MCIS (Arizona only)
- Provider Online Portal – HSConnect
- Quick Reference Guide
- Quick Reference Guide – Oncology [PDF]
- Special Needs Plans Model of Care Training
- Stay Informed – Provider Updates
Prior Authorization Request Forms
- Drug Prior Authorization Request Forms Coverage Determinations
- Inpatient Admission Request Form [PDF]
- Prior Authorization Request Form [PDF]
- Prior Authorization Request Form – Durable Medical Equipment (DME) [PDF]
- Prior Authorization Request Form – Home Health Care (HHC) [PDF]
- Prior Authorization Request Form – Inpatient Post-Acute [PDF]
- Prior Authorization Request Form – Transplant [PDF]
Prior Authorization Requirements
2022
- Prior Authorization Requirements – April 2022 [PDF]
- Prior Authorization Requirements – January 2022 [PDF]
2021
- Prior Authorization Requirements – October 2021 [PDF]
- Prior Authorization Requirements – July 2021 [PDF]
- Prior Authorization Requirements – April 2021 [PDF]
- Prior Authorization Requirements – January 2021 [PDF]
2020
- Prior Authorization Requirements – October 2020 [PDF]
- Prior Authorization Requirements (Arizona only) [PDF]
- Prior Authorization Requirements – July 2020 [PDF]
- Prior Authorization Requirements – April 2020 [PDF]
- Prior Authorization Requirements – January 2020 [PDF]
- Prior Authorization Requirements – October 2019 [PDF]
Provider Information Change Forms
- Alabama, Georgia, North Carolina, North Florida, South Carolina,and South Mississippi [PDF]
- Arizona [PDF]
- Colorado, New Mexico, and Utah [PDF]
- Delaware, Maryland, New Jersey, Pennsylvania, and Washington DC [PDF]
- Illinois [PDF]
- Kansas City and Missouri [PDF]
- Tennessee [PDF]
- Texas [PDF]
- Texas MMP/Texas StarPlus [PDF]