Claims | Clinical/UM | COVID-19 Forms | Network Mgt | Provider Relations | Quality Mgt
Claims Dept Forms
- Claims Batch Header Form
- CMS-1500 Claim Form
- NPI Notification Letter
- NPI Submission Form – Individual Practitioner
- NPI Submission Form – Organizational Provider
- Online Services Account Request Form
- Online Account Request Form – Access for Multiple Providers
- Online Services Intermediary Authorization Form
- Timely Filing Waiver Request Form
- UB-04 Claim Form
Clinical / Utilization Management Forms
Authorization Forms
- ACT CTT Continued Stay Request
- ACT CTT Pre-Certification Request
- Acute Partial Hospitalization (APH) Auth Request Form
- Adult Non-Acute Partial Hospitalization Pre-Cert Authorization Request
- Adult Non-Acute Partial Hospitalization Continued Stay Authorization Request
- Authorization Request Form for ASAM 2.1
- Authorization Request Form for ASAM 2.5
- Case Conceptualization Tool (Fayette and Beaver Counties only)
- Child/Adolescent Partial Hospitalization Pre-Cert Authorization Request
- Child/Adolescent Partial Hospitalization Continued Stay Authorization Request
- Child/Adolescent School-Based Partial Hospitalization Pre-Cert Authorization Request
- Child/Adolescent School-Based Partial Hospitalization Continued Stay Authorization Request
- Continuation Rights Form
- Fayette County Forensic Diversion Recovery Program (FDRP) Auth Request Form
- HLOC Substance Use Authorization Request Form – Pre-Cert
- HLOC Substance Use Authorization Request Form – Continued Stay
- LTSR Continued Stay Request
- LTSR Pre-Certification Request
- Methadone Maintenance Precert
- Methadone Maintenance Continued Stay Review
- Methadone Maintenance Discharge
- Mobile Mental Health Treatment – Precert
- Mobile Mental Health Treatment – Continued Stay Authorization
- Psychological Registration Form
- Psych Rehab Pre-Cert Form
- Psych Rehab Continued Stay Request
- Retro Authorization Form – Pennsylvania Medicaid Only
- RTF Request for Hold Bed Days
- Substance Use Disorder Registration Form
Family Based Mental Health Services
- FBMHS FBH RFT Calculator
- Family Based Review Process Instructions
- FBMHS Recommendation
- Family Based Review Precert Form
- Family Based Mental Health Services 16 Week Review Form
- Family Based Mental Health Services 24 Week Review Form
- Family Based Mental Health Services Booster Registration Form
- Family Based Review Discharge Form
- How to Request Family Based Services Authorizations via ProviderConnect
Medicare Primary Insurance Forms
Outpatient Review Form
- Mental Health Intensive Outpatient Precert
- Mental Health Intensive Outpatient Auth Request (CSR)
- Mobile Medications Precert
- Mobile Medications CSR
- ORF Instructions
- Outpatient Psych ORF
Other Forms
- Grievance Release Form
- Integrated Care Release of Information
- Medical Exception Request Worksheet Form
- PCIT Fidelity Tool
- RTF Discharge Form
Single Case Agreements
- SCA Companion Guide
- SCA Online Request Form
- SCA Online Form Child Adolescent LOC
- SCA ACT Continued Stay Request
- SCA ACT Pre-Cert
- SCA Acute Partial Hospitalization Auth Request
- SCA Adult Non-Acute PHP Pre-Cert
- SCA Adult Partial Non-Acute CSR
- SCA BCM Service Coordination Pre-Cert
- SCA Methadone CSR
- SCA Methadone Pre-Cert
- SCA MH IOP Auth Request
- SCA MH IOP CSR
- SCA MH ORF
- SCA Mobile Medications CSR
- SCA Mobile Medications Pre-Cert
- SCA Partial Child Adol CSR
- SCA Partial Child Adol Precert
- SCA Psych Rehab CSR
- SCA Psych Rehab Pre-Cert
- SCA Retro
- SCA School Based PRT CSR
- SCA School Based PRT Pre-Cert
- SCA SUD IOP ASAM 2.1
- SCA SUD Outpatient
- SCA SUD PHP ASAM 2.5
- SCA SUD Registration
- SCA Psychological Evaluations Request (PER) Form for Out-of-Network Providers