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Provider Forms

Claims

Corrected Claim Billing Guide

 

Prior Authorizations

2019 Prior Authorization Guide - Idaho Medicaid Plus
2019 Prior Authorization Code Matrix - Idaho Medicaid

 

Provider Appeals

Provider Appeals Form (Medicaid)
Provider Appeals Submission Training – Web Portal


Pharmacy

Pharmacy Prior Authorization Form


Abortion, Hysterectomy and Sterilization

Sterilization Consent Form (HWO034)


Other Forms and Resources

In Office Lab Test List
Notification of Change Form
Significant Change Form
Non-Contracted Provider Contract Request Form


*Providers requesting to contract for a new line of business.

Contracted Practices/Groups Making Changes

Provider Information Change Form*
Agency Change Form


*Add/change/term information for contracted providers/groups.

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