Contracting

• Contract Request Form (PDF)

Credentialing Material

• Application Packet (PDF)
• MID Form (PDF)
• W-9 Form (PDF)
• CAQH Brochure (PDF)

Forms & Applications

• Prior Authorization Form (PDF)
• Prior Authorization Tutorial Fax Form (PDF)
• Prior Authorization Form Outpatient Therapy & Rehab Services (PDF)
• Prior Authorization Form Pain Management (PDF)
• Provider Notification of Pregnancy Form (PDF)
• Prenatal Vitamin Form (PDF)
• Connections Referral Form (PDF)
• Claim Dispute Form (PDF)
• Provider Complaint Form (PDF)
• Hospice Physician Form (PDF)
• DOM Hysterectory Acknowledgement Form (PDF)
• Sterilization Consent Form (PDF)
• Application for MS Family Planning Services (PDF)
• Provider CM DM Referral Form (PDF)
• Univita Referral Form (PDF)
• Univita CPAP-BIPAP Therapy Order Form (PDF)
• Univita CPAP Assessment Form (PDF)
• Univita Oxygen Therapy Request Form (PDF)
• Univita Wheelchair Evaluation Form (PDF)
• Foster Care Health Information Form (PDF)

Manuals & Reference Guides

• 2012 Provider Manual (PDF)
• 2012 Provider Claims Filing Manual (PDF)
• Prior Authorization List (PDF)
• Provider Reference Card (PDF)
• PaySpan (PDF)
• HEDIS Quick Reference Guide Adult (PDF)
• HEDIS Quick Reference Guide Pediatric (PDF)
• HEDIS Quick Reference Guide Women (PDF)
• Quick Reference Guide for EPSDT Codes (PDF)
• Dentaquest Office Reference Manual (PDF)
• DOM Provider Manual Regarding Hysterectomy (PDF)
• DOM Provider Manual Regarding Sterilizations (PDF)

Pharmacy

• Preferred Drug List (PDF)
• Quick Reference Drug List (PDF)
• Abridged Preferred Drug List (PDF)
• Magnolia PDL Alternatives (PDF)
• US Script Medication PA Request Form (PDF)
• US Script Specialty Medication PA Form (PDF)
• US Script Enteral/Nutritional PA Request Form (PDF)
• Biopharmaceutical Pharmacy Program (PDF)
• Appropriate Use and Safety Edits (PDF)