FORMS AND PRACTICE SUPPORT

• Depression Disease Management Program Referral Form
• Electroconvulsive Therapy Initial Treatment Request Form
• Inpatient Hospitalization Notice of Discharge
• Inpatient Treatment Request Form
• Outpatient Treatment Request Form
• Psychological Testing Request Form

• Appeals / Claim Disputes Form
• Claim Payment Process
• Claim Reconsideration
• Electronic Claims Enrollment
• ICD-10 Information
• How to Read an Explanation of Payment (EOP)
• Provider Online Portal – HSConnect
• Provider Online Portal – Claimstat MCIS (Arizona only)

• Alabama, North Florida, and Southern Mississippi
• Arkansas
• Colorado, New Mexico and Utah
• Delaware, Maryland, New Jersey, Pennsylvania, Virginia, and Washington DC
• Florida - Central
• Florida - South
• Georgia
• Illinois
• Kansas City
• North Carolina and South Carolina
• Ohio
• Tennessee
• Texas

• Alabama, North Florida, and Southern Mississippi
• Arkansas
• Colorado, New Mexico and Utah
• Delaware, Maryland, New Jersey, Pennsylvania, Virginia, and Washington DC
• Florida - Central
• Florida - South
• Georgia
• Illinois
• Kansas City
• North Carolina and South Carolina
• Ohio
• Tennessee
• Texas

2022

Drugs/Biologics Part B Step Therapy Quick Reference Guides

• Part B Step Therapy Quick Reference Guide Effective 1/1/2022

Drugs/Biologics Part B Precertification Forms

• Drugs/Biologics Part B Precertification Form
• Durable Medical Equipment (DME) Diabetic Testing Supplies Request

Drugs/Biologics Part B Step Therapy Precertification Forms

• Avastin
• Herceptin
• Neupogen and Granix
• Remicade
• Rituxan
• Udenyca Fulphila
• Viscosupplement

2021

• Drugs/Biologics Part B Precertification Form
• Drugs/Biologics Part B Precertification Form (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form – Durable Medical Equipment (DME) Diabetic Testing Supplies Request
• Drugs/Biologics Part B Precertification Form – Durable Medical Equipment (DME) Diabetic Testing Supplies Request (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Avastin
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Avastin (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form – Part B Step Therapy Nivestym-Neupogen (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Herceptin
• Drugs/Biologics Part B Precertification Form (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form – Part B Step Therapy Neupogen and Granix
• Drugs/Biologics Part B Precertification Form – Part B Step Therapy Remicade
• Drugs/Biologics Part B Precertification Form – Part B Step Therapy Remicade (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Rituxan
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Rituxan (AZ Only) Effective 10/8/2021
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Udenyca Fulphila
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Visco
• Drugs/Biologics Part B Precertification Form - Part B Step Therapy Visco (AZ Only) Effective 10/8/2021
• Part B Step Therapy Quick Reference Guide Effective 1/7/2021-12/31/2021
• Part B Step Therapy Quick Reference Guide (AZ Only) Effective 10/8/2021
• Part B Step Therapy Quick Reference Guide Effective 1/1/2022

• 360 Comprehensive Assessment Form 2020
• Behavioral Health
• Cigna Medicare ID Cards
• Clinical Practice Guidelines – 2021
• Patient Support Programs
• Provider Directory
• Provider Online Portal – Claimstat MCIS (Arizona only)
• Provider Online Portal – HSConnect
• Quick Reference Guide Print Size: Legal paper (8.5 x 14 in)
• Quick Reference Guide – Oncology
• Special Needs Plans Model of Care Training
• Stay Informed – Provider Updates

• Drug Prior Authorization Request Forms Coverage Determinations
• Inpatient Admission Request Form
• Prior Authorization Request Form
• Prior Authorization Request Form – Durable Medical Equipment (DME)
• Prior Authorization Request Form – Home Health Care (HHC)
• Prior Authorization Request Form – Inpatient Post-Acute
• Prior Authorization Request Form - Transplant

2021

• Prior Authorization Requirements – October 2021
• Prior Authorization Requirements – July 2021
• Prior Authorization Requirements – April 2021
• Prior Authorization Requirements – January 2021

2020

• Prior Authorization Requirements – October 2020
• Prior Authorization Requirements (Arizona only)
• Prior Authorization Requirements – July 2020
• Prior Authorization Requirements – April 2020
• Prior Authorization Requirements – January 2020
• Prior Authorization Requirements – October 2019

• Alabama, Georgia, North Carolina, North Florida, South Carolina,and South Mississippi
• Arizona
• Colorado, New Mexico, and Utah
• Delaware, Maryland, New Jersey, Pennsylvania, and Washington DC
• Illinois
• Kansas City and Missouri
• Tennessee
• Texas
• Texas MMP/Texas StarPlus

• Provider Manual – 2022
• Provider Manual – 2021
• Provider Manual – 2020
• Out of Network Manual
• Regulatory Highlights Guide - 2021