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Forms

Access key forms for authorizations, claims, pharmacy and more.

Appeals and Grievances

Authorizations

A copy of the IFSP must be attached to the PA Request.

Hospice Prior Authorization Request Form

Transplant Authorization Request Form

Surgery Prior Authorization Form

Behavioral Health

Behavioral Health Service Request Form: Applied Behavior Analysis (ABA) For Autism Spectrum Disorder

South Carolina Department of Mental Health CMHC Treatment Review & Authorization Request

Pharmacy

Drug Prior Authorization Requests Supplied by the Physician/Facility

Other Provider Forms

Use this form to request a PCP change for a member.

Refund Check Information Sheet* (RCIS)

Guidelines for submitting HEDIS Flat Files, ESD, and Active DX codes.

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Last Updated On: 3/24/2021