丝瓜短视频

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Earn rewards for keeping your patients healthy!

Flu shots can keep people healthy and out of the hospital. With so many misconceptions surrounding the flu shot, we need your help to keep 丝瓜短视频 members healthy. To support you, we will be rewarding you $20 for each flu shot you administer to 丝瓜短视频 patients in your practice!

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Below, you’ll find essential forms and documents providers need to best serve our members.

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

Contracting and Practice Changes

. If you have additional general questions about the New Health Partner Contract Form, call Provider Services at 1-833-230-2176.

to alert 丝瓜短视频 to changes in your practice. Login to the portal and select “Provider Maintenance” from the navigation.

Provider Debarment Form

Use this form to provide attestation of provider information.

Member-Related Forms

Primary Care Provider (PCP) Change Request Form

Use this form to request a change in PCP.

Coordination of Care and Release of Information Form

Use this form to share patient care information with another provider. Please note the release of information clause at the end of page 2.

Medical Prior Authorization

Medical Prior Authorization Form

Submit this form to request prior authorization for a medical procedure.

Claims

Overpayment Recovery Form

Providers may submit Recovery Requests via the Provider Portal.

Claim Refund Check Form

Mail your refund check, this form and any other required documentation to 丝瓜短视频.

Itemized Bill Cover Sheet

Submit this cover sheet and itemized statement for high dollar claims.

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

Waiver of Liability Form for Claim Appeals

Submit this form with all non-participating provider claims appeals. CMS requires this form or appeal request will be dismissed.

Provider Appeal Request Form

Submit this form to request an appeal for an authorization, post-service, contract or other issue.

Appointment of Representation (AOR) Form

Submit this form if you are not a physician or a physician representative.

Expedited Appeal Form

If you feel a standard appeal time frame will harm your patient, please complete and mail this form to the address provided

Fraud, Waste and Abuse

Fraud, Waste and Abuse Reporting Form

Submit this form to report suspected fraud, waste or abuse.

System Details

丝瓜短视频

Forms

Contracting and Practice Changes

Provider Debarment Form

Member-Related Forms

Primary Care Provider (PCP) Change Request Form

Coordination of Care and Release of Information Form

Medical Prior Authorization

Medical Prior Authorization Form

Claims

Overpayment Recovery Form

Claim Refund Check Form

Itemized Bill Cover Sheet

Provider Standard Claim Dispute Form

Appeals

Waiver of Liability Form for Claim Appeals

Provider Appeal Request Form

Appointment of Representation (AOR) Form

Expedited Appeal Form

Fraud, Waste and Abuse

Fraud, Waste and Abuse Reporting Form

Overview

Administrative Policies

Medical Policies

Reimbursement Policies

Pharmacy Policies

Overview

COVID-19 Updates

Past Updates & Announcements

Access Your My 丝瓜短视频 Account

Access Your My 丝瓜短视频 Account

Access YourProvider PortalAccount

Grow Your Business

Grow Your Business

Forms

Contracting and Practice Changes

Provider Debarment Form

Member-Related Forms

Primary Care Provider (PCP) Change Request Form

Coordination of Care and Release of Information Form

Medical Prior Authorization

Medical Prior Authorization Form

Claims

Overpayment Recovery Form

Claim Refund Check Form

Itemized Bill Cover Sheet

Provider Standard Claim Dispute Form

Appeals

Waiver of Liability Form for Claim Appeals

Provider Appeal Request Form

Appointment of Representation (AOR) Form

Expedited Appeal Form

Fraud, Waste and Abuse

Fraud, Waste and Abuse Reporting Form

Access Your
My 丝瓜短视频
Account

Access Your
My 丝瓜短视频
Account

Access Your
Provider Portal
Account