Forms and Reference Material

Forms and Reference Material

Forms and Reports

21st CCA Tipsheet: Prevent Claim Denials

Abortion Consent Form

Advance Directive Form

Applied Behavioral Analysis (ABA) Prior Authorization Request Form

Attendant Care Monthly Missed Visits/Hours/Shifts Report

Behavioral Health Discharge Notification Form

Disclosure Form and Instructions

Durable Medical Equipment (DME) Prior Authorization Request Form

EPSDT Member Outreach Form

Home Health Aide (HHA) Shifts Prior Authorization Request Form

Home Health Monthly Missed Visits/Hours/Shifts Report

Home Health Visits Prior Authorization Request Form

Inpatient Psychiatric Admission Prior Authorization Request Form

Maternity Outcome Form

Member Appeal Form

Member Appeal – Representation Consent Form

Member Grievance Form

Member Outreach Form

Member Request for Authorization to Use and Disclose

Obstetrical Needs Assessment Form (ONAF)

Outpatient Behavioral Health Prior Authorization Request Form

Outpatient Therapy Services Prior Authorization Request Form

PCP Transfer Form

Pediatric Financial Management Service (FMS) and Self-Directed Attendant Care (SDAC) Prior Authorization Request Form

Pediatric Respite Prior Authorization Form

Private Duty Nursing Prior Authorization Request Form

Provider Appeals Submission Form

Provider Change Form

Provider Complaint Forms

Provider Language Access Guide for Interpretation Services

Provider Self-Audits and Overpayments Form – Medicaid

Provider Self-Audits and Overpayments Form – D-SNP

Quality of Care/Quality of Service Concern External Reporting Form

Referral Request for Maternal Opioid Use Disorder (MOUD) Treatment

Request for Medicaid Drug Exception Form

SSBCI Attestation Form

Sterilization Consent Form

Substance Use Disorder Prior Authorization Request Form

Substance Use Disorder (SUD) 48-Hour Notification of Admission (ASAM) Form

Guides and Checklists

Anti-Fraud Plan

Fraud and Abuse Laws and Regulations

FWA Auditing and Monitoring Plan

MOM Options Rewards Brochure

PNC Healthcare's Claim Payments & Remittances User Guide

Point to Your Language Placard for Interpretation Services

Private Duty Nursing Letter of Medical Necessity Requirements Checklist

Private Duty Nursing Quick Guide

Provider Self-Audit Information

Billing Guide: Treating Pregnant and Parenting People with Substance Use Disorders – Care Management Services

Billing Guide: Treating Pregnant and Parenting People with Substance Use Disorders – Trauma-Informed Care

Billing Guide: Treating Pregnant and Parenting People with Substance Use Disorders – Interprofessional Consultation

Interprofessional Consultation Billing Reference Sheet

Implementation Review Checklist for New Codes

Need more information?

Call Provider Services at 1-844-325-6251, Monday–Friday, 8 a.m.–5 p.m.

Be Informed

Be Informed

About Highmark Health Options

About Highmark Health Options