Provider Contracting and Credentialing

Provider Information Update Form

Practitioner Enrollment Application

Disclosure of Ownership and Control

Provider Contract Request Form

Recoupments and Reimbursements

Recoupment Form

Prior Authorizations

MSCAN

	Prior Authorization LookUp Tool
	Prior Authorization Codification Matrix
	Prior Authorization Request Form
	Behavioral Health Prior Authorization Form
	Prescription Prior Authorization Form

CHIP

	Prior Authorization LookUp Tool
	Prior Authorization Codification Matrix
	Prior Authorization Request Form (Coming Soon)
	Behavioral Health Prior Authorization Form (Coming Soon)
	Prescription Prior Authorization Form (Coming Soon)

Reconsiderations and Appeals

MSCAN

Claim Reconsideration Request Form

Pre-Service Appeal Request Form (Coming Soon)

CHIP

Claim Reconsideration Request Form (Coming Soon)

Provider Clinical Appeal Request Form (Coming Soon)

Pregnancy

MSCAN

Pregnancy Notification Form

CHIP

Pregnancy Notification Form (Coming Soon)

Other Forms and Resources

Community Connector Referral Form

Request to Change Primary Care Provider

Weight Watcher Referral Form