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Forms / formulary

Medicaid list of covered drugs (Formulary) – effective 12/1/2021 (PDF)

List of covered drugs for SNBC members with Medicare coverage (Formulary) - effective 9/1/2021 (PDF)

Behavioral Health

Client placement authorization (PDF)

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Diagnostic assessment (PDF)

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Mental health TCM notification form (PDF)

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Psychological testing form (PDF)

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Service authorization form for ARHMS, IRTS and ACT services (DOC)

Download

Claims and payment

Automated clearinghouse ACH funds transfer request (PDF)

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Claims adjustment reconsideration request (PDF)

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Client placement authorization (PDF)

Download
Non-contracted provider information form

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W9 for contracted providers (PDF)

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W-9 for non-contracted providers (PDF)

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Contracting and credentialing

Contracted provider information form (PDF)

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Disclosure of ownership changes form (PDF)

Download
Facility credentialing application (PDF)

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Location add/term/change form (PDF)

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Location and practitioner roster template (XLS)

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Network contract request form (PDF)

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Practitioner initial credentialing application (PDF)

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Practitioner re-credentialing application (PDF)

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Practitioner add/term/change form (PDF)

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Quarterly complaint form (DOCX)

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Site visit checklist (PDF)

Download

Pharmacy

Drug reconsideration request (PDF)

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Prescription drug prior authorization form (PDF)

Download

Release of information

Patient authorization for release of information form (PDF)

Download

Restricted recipient

Medical referral for MRRP members (PDF)

Download

Service authorizations

Advanced recipient notice of non-covered service-item

Download
Continuity of care (PDF)

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Inpatient admissions notification (PDF)

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Intensive care management (ICM) referral (PDF)

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Neuropsych testing service authorization form (DOC)

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Partnered provider out-of-network referral (PDF)

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Psychological testing form (PDF)

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Service authorization request (PDF)

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Service authorization request form for ARHMS, IRTS and ACT services (DOC)

Download
Substitute health service request form (PDF)

Download

Provider updates

Provider updates

Electronic transaction guidelines

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