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Forms / formulary

Medicaid list of covered drugs (Formulary) – effective 1/1/2022 (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)

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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)

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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)

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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)

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Pharmacy

Drug reconsideration request (PDF)

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Prescription drug prior authorization form (PDF)

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Release of information

Patient authorization for release of information form (PDF)

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Restricted recipient

Medical referral for MRRP members (PDF)

Download

Service authorizations

Advanced recipient notice of non-covered service-item

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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)

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Substitute health service request form (PDF)

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Provider updates

Provider updates

Electronic transaction guidelines

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