丝瓜短视频

We have compiled all of the essential forms in one place for you to utilize. Select the applicable form(s) for reporting, credentialing, claims, and more.

Note: You may need to download  to open these files.

Contracting, Credentialing and Practice Changes Forms

• Navigate 丝瓜短视频 PASSE Common Roster Template
  This form should be completed by large facilities needing to add a large number of providers. Providers may attach the completed form to their  application, or email the form to us if they’ve already filled out an application.
• Navigate CCVS Provider Authorization and Release Form
  Submit this form to authorize release of credentialing information to 丝瓜短视频 PASSE.
• Navigate Debarment Form
  Use this form to provide ownership of disclosure information.
• Navigate HCBS Credentialing Application
  This form should be completed by HCBS providers to be credentialed with 丝瓜短视频.
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  Submit this form if you are interested in becoming a 丝瓜短视频 PASSE™ provider. Need help? Refer to the Navigate New Health Partner Contracting Checklist. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2100.
• Navigate Organizational Credentialing Application
  This form should be completed by organization/facility for credentialing.
• Navigate Provider Attestation Form
  Submit this form to attest to practice competency prior to working with 丝瓜短视频 PASSE.
• Provider Change Request Form (coming soon)
  Submit this form to alert 丝瓜短视频 PASSE to report a change within your practice.
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  Use this form to provide attestation of completing education requirements.
• Provider Maintenance Form
  Use the  to alert 丝瓜短视频 PASSE to changes in your practice. Log in to the portal and select “Provider Maintenance” from the navigation.

Incident Reporting Form

• Navigate Incident Report Form
  To report incidents, HCBS and PRTF providers should utilize the DHS DDS Incident Reporting Portal online, if they have access to the Portal. If a provider does not have access to the online Portal, the Navigate Arkansas PASSE Incident Report Form should be completed and emailed to 丝瓜短视频 PASSE and to DHS.

Member-Related Forms

• Navigate Independent Reassessment Dates Form
  Submit this form to request a member’s Independent Reassessment dates.
• Navigate Interpreter Service Request Form
  Submit this form to request interpretation services for an upcoming appointment for a 丝瓜短视频 members.

Pharmacy Prior Authorization Forms

• Navigate Hepatitis C Virus (HCV) Medication Therapy Request Sheet
  Submit this form to request prior authorization for hepatitis C treatment.
• Navigate H.P. Acthar® Gel (Corticotropin Injection) Infantile Spasm Prior Authorization Request Form
• Navigate Pharmacy Prior Authorization Request Form
  Submit this form to request prior authorization to prescribe certain medications, as outlined in the 丝瓜短视频 PASSE member’s Preferred Drug List (PDL).
• Navigate Specialty Pharmacy Prior Authorization Request Form
  Submit this form to request prior authorization to prescribe specialty pharmacy medications.
• Navigate Statement of Medical Necessity Information Form for INGREZZA® (valbenazine) or AUSTEDO® (deutetrabenazine)
  Submit this form to request prior authorization to prescribe Ingrezza (valbenazine) or Austedo (deutetrabenazine).
• Navigate Statement of Medical Necessity for Adult Use of a C-II stimulant
  Submit this form to request prior authorization to prescribe a C-II stimulant for patients 19 years of age or older with attention-deficit/hyperactivity disorder (ADD/ADHD).
• Navigate Statement of Medical Necessity for Xolair® (Omalizumab)
  Submit this form to request prior authorization to prescribe Xolair (Omalizumab).
• Navigate Sublocade® (buprenorphine SQ Injection) VIVITROL® (naltrexone ER IM injection) Statement of Medical Necessity
  Submit this form to request prior authorization to prescribe Vivitrol.
• Navigate Synagis® Prior Authorization Form
  Submit this form to request prior authorization to prescribe Synagis.

Medical Prior Authorization Form

• Navigate Medical Prior Authorization Request Form
  Submit this form to request prior authorization for a medical service.

HCBS/Waiver Provider Authorization Form

• Home & Community Based Services (HCBS)/Waiver Provider Authorization (coming soon)
  Submit this form to request prior authorization for a HCBS/Waiver service.

Claims Forms

• Navigate Claim Refund Check Form
  Mail your refund check, this form and any other required documentation to 丝瓜短视频 PASSE.
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  Submit this form to enroll with ECHO Health, our electronic funds transfer partner.
• Navigate Itemized Bill Cover Sheet
  Submit this cover sheet and itemized statement for high dollar claims.
• Navigate Overpayment Recovery Form
  Submit this form to offset overpaid claims against a future payment.
• Navigate Pharmacy Paper Claims Form
  Submit this to Express Scripts^® (ESI) using the instructions on the form.
• Navigate Provider Standard Claim Dispute Form
  Submit this form to dispute a standard claim. The best way to submit is via the Provider Portal. It can also be mailed to the address on the bottom of the form.

Appeals Forms

• Navigate Consent for Provider to File an Appeal on Patient/Member's Behalf
  Submit this form to request an appeal on behalf of a member.
• Navigate Provider Appeal Form
  Submit this form to request an appeal for a claim denial or a medical necessity/utilization management decision.

Fraud, Waste and Abuse Form

• Navigate Fraud, Waste and Abuse Reporting Form
  Submit this form to report suspected fraud, waste or abuse.