Forms for providers

Claims

Sign in to check the status of your claim adjustment and appeal requests. Select Claim Adjustments and Appeals from your menu.
• Claim Adjustment Requests - online
  Add new data or change originally submitted data on a claim
  • Claim Adjustment Request - fax
• Claim Appeal Requests - online
  Reconsideration of originally submitted claim data
  • Claim Appeal Form - fax
  • Restricted Recipient Program ER Claim Reconsideration/appeal - online
  • Restricted Recipient Program ER Reconsideration/appeal 
• Claim Attachment Submissions - online
  • Dental Claim Attachment - fax
  • Medical Claim Attachment - fax
• Claim Correspondence - online

Contracting, Credentialing and Enrollment

• Annual Interpreter Services Roster
• Credentialing submission
  • Check the status of a new credentialing application
  • Minnesota Uniform Credentialing application
  • MTM credentialing application
  • Initial Dental Credentialing application
  • Minnesota Uniform Practitioner Change form
• Disclosure of Ownership & Management Information
• Join our network
• New Site Location Request form
• Offshore Attestation Form
• Out of Network/National Medical Provider Updates
• Out of Network/National Dental Provider Updates
• Universal Consultant Confidentiality Agreement

• Disease, Case and Lifestyle Management
• Hospital Admission/Discharge
• Hospice Communication form
• Minnesota Rare Disease Intake form
• Network Adequacy Request – Benefit review form
• Never Event Reporting
• Restricted Recipient Program (RRP) provider referral
• Self Reported Complaints

Forms for submitting prior authorization requests

Fillable forms work best when using the Adobe Acrobat Reader DC application. Visit get.Adobe.com/reader for more information.

• Acute Rehabilitation facility admission review
• Airway Clearance System/Chest Compression Generator System review
• Balloon Sinuplasty review
• CFSS PCA Vendor Change Request
• CPM review
• Deep Brain Stimulation review
• DHS Nursing Facility (NF) Communication Form DHS-4461
• Durable Medical Equipment (DME) review
• Enteral Nutrition (Formula) review
• Enteral Nutrition (Formula) review - Minnesota Health Care Programs
• Fixed Wing Air Ambulance Transportation review
• Genetic Testing review
• Home Health Care review
• Hospital Bed review
• LTACH facility admission review
• Medical-Dental Procedures - Accidental Dental review
• Medical-Dental Procedures - Facility-General Anesthesia review
• Medical-Dental Procedures - Oral Surgery for Dental Conditions review
• Medical-Dental Procedures - Orthognathic Surgery review
• Medical-Dental Procedures - Surgical Intervention for TMD review
• Medical gender services/surgery review
• Mental Health Partial Hospitalization review
• Mental Health Residential Treatment Services review
• PCA Assessment review
• Phrenic Nerve review
• Pneumatic Compression Devices review
• Procedures review
• Radiofrequency Ablation Spine review
• Sacroiliac (SI) injections to treat SI joint pain review
• Seat lift mechanism review
• Site of Service-Attended Polysomnography for Evaluation of OSA review
• Skilled Nursing Facility review form
• Specialty Mattress Gp I or Gp II review
• Spinal Cord Stimulator review
• Spinal Fusion-Lumbar review
• Substance Use Disorder Services review
• Transcranial Magnetic Stimulation review
• Transplant Prior Notification review
• Urine Drug Testing review
• Upper airway, hypoglossal nerve stimulation therapy for obstructive sleep apnea review
• Varicose vein procedures of the lower extremities review
• Weight Loss Surgery review
• Wheelchair review

Forms for dental services and requests

• Accidental Dental authorization form
• Clinic address change form
• Clinic Legal or Marketing name change form
• Initial Dental Credentialing application
• Dental Provider Change Notice
• W-9 form for Tax Id Changes
• Prior Notification of Diabetes or Pregnancy
• Provider Notification for HPCare Add'tl Prophys

Forms for pharmacy services and requests

• Cell and Gene Attestation form - Hemophilia A
• Cell and Gene Attestation form - Hemophilia B
• Cell & gene Attestation – Sickle Cell
• CMS standard format/CCD creator  
• Disease, Case and Lifestyle Management
• MTM credentialing application
• New Drug Request
• Prior Authorization / Exception - online
  • Minnesota Uniform Prior Authorization and Formulary Exception
  • Prior Authorization / Exception - Fax