Forms and Documents

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Provider Manual 

2024 Marketplace Provider Manual

Download 2024 Marketplace Provider Manual

2023 Marketplace Provider Manual

Download 2023 Marketplace Provider Manual

Prior Authorization

2024 Q3 Marketplace Prior Authorization Code Matrix

Download 2024 Q3 Marketplace Prior Authorization Code Matrix

Prior Authorization LookUp Tool

Download Prior Authorization LookUp Tool

Prior Authorization Request Contact Information

Download Prior Authorization Request Contact Information

Behavioral Health Prior Authorization Form

Download Behavioral Health Prior Authorization Form

Prescription Prior Authorization Form

Download Prescription Prior Authorization Form

2024 Prior Authorization Request Form

Download 2024 Prior Authorization Request Form

Reconsiderations and Appeals

Claim Reconsideration Request Form

Download Claim Reconsideration Request Form

Preservice Appeal Request Form

Download Preservice Appeal Request Form

Frequently Used Forms