Forms and Resources

Contracting

• Join Our Network
• Behavioral Health Join Our Network

Non Participating Providers

• Non-Participating Providers (PDF)
• Non-Participating Provider Prior Authorization Policy (PDF)

Credentialing

• CAQH Brochure (PDF)
• Hospital Ancillary Clinic Credentialing Application (PDF)
• Magnolia Credentialing Application Packet (PDF)
• MID Form (PDF)
• Ownership and Controls Disclosure Form (PDF)
• Provider Data Form (PDF)
• Provider and Practitioner Credentialing Rights (PDF)
• Provider Update Form for Contracted Providers (PDF)
• W-9 Form (PDF)

• Care Management Referrals (PDF)
• Provider Care Management / Disease Management Referral Form (PDF)

• Claim Appeal Form (PDF)
• Claim Reconsideration Form (PDF)
• Claims FAQs (PDF)
• CMS 1500 Claims Form Instructions (PDF)
• FQHC Billing Information
• Inpatient Hospital Claims Coding
• PaySpan (PDF)
• RHC Billing Information
• Taxonomy Code Billing Requirement (PDF)

• Discharge Consultation Documentation Form (PDF)
• Provider Notification of Pregnancy Form (PDF)

Dental Sedation Scoring Tool (PDF)

• EPSDT Brochure - Age 0-2 Years (PDF)
• EPSDT Brochure - Age 0-6 Years (PDF)
• EPSDT Brochure - Age 3-8 Years (PDF)
• EPSDT Brochure - Age 9-13 Years (PDF)
• EPSDT Brochure - Age 14-20 Years (PDF)
• EPSDT Brochure - Age 7-21 Years (PDF)

• Member Appeals Authorized Representative Form (PDF)
• Provider Complaint-Grievance Form (PDF)

• Adult Wellness Visit Checklist (PDF)
• Connections Referral Form (PDF)
• Foster Care Health Information Form (PDF)
• Primary Care Provider (PCP) Change Form (PDF)

• Pharmacy Reimbursement
• Preferred Drug List (PDL)
• Division of Medicaid Preferred Drug List Changes
• Prior Authorization Forms

• Prior Authorization List (PDF)
• Inpatient Prior Authorization Form (PDF)
• Outpatient Prior Authorization Form (PDF)
• Prior Authorization Tips - Urgent Requests
• Prior Authorization Tips - Timeliness of Prior Authorization Requests
• Prior Authorization Tips - Non-Participating Providers Documentation Requirements
• Prior Authorization Tips - Doctor's Orders
• Prior Authorization Tips - Do Not Use Copies of Old PA Forms
• Prior Authorization Tips - How to Fill Out the PA Form
• Prior Authorization Tips - Removal of PA for Observation, CPAP and BiPAP

• Magnolia Health MississippiCAN Provider Manual (PDF)
• 2023 Wellcare by Allwell Provider Manual (PDF)
• Envolve Dental Provider Manual (PDF)
• Envolve Vision Provider Manual (PDF)

• Access and Availablity Standard Guidelines (PDF)
• Cultural Competency Plan (PDF)

• 2023 Wellcare by Allwell Provider Manual (PDF)
• Wellcare by Allwell Claim Dispute Form (PDF)
• Wellcare by Allwell Inpatient Prior Authorization Form (PDF)
• Wellcare by Allwell Outpatient Prior Authorization Form (PDF)
• Contract Request Form (PDF)

For Ambetter information, please visit our Ambetter website.