Find the provider forms you need in our fully downloadable provider forms library.

Find the provider forms you need in our fully downloadable provider forms library.

Provider forms: New Jersey

Claims Requirements and Communications

• Claims Submission Toolkit
• Implant Reimbursement Request Form
• LTAC precertification form
• Off Cycle Concierge Attestation Form
• Off Cycle Concierge Questionnaire
• Overpayment/Refund Form
• Post-Acute Facility Admission Guide
• Provider change form
• Continuation of Care Request Form
• Request to Update Procedure Code(s) on an Existing Authorization
• UB-04 Claim Form and Instructions
• Waiver of Liability Statement

Claims Appeals

• Emergency Room Review Form
• Health Care Provider Application to Appeal a Claims Determination
• Medicare Non-Contracted Provider Payment Dispute Process
• Medicare Provider Appeal Process for Non-Contracted Providers
• Out-of-Network Provider Claim Negotiation Form
• Payment Dispute Decision (PDD) Request Form
• Peer-to-Peer Request Form
• Consent to Appeals of UM Determinations and Medical Release

HIPAA

• HIPAA Authorization for Disclosure of Health Information
• HIPAA Personal Representative Request Form

Policies

• AIM Preauthorization/ RQI Request Fax Form

Other

• Clinician Collaboration Form

Provider forms: Pennsylvania

• Clinician Collaboration Form
• Continuation of Care Request Form
• Dental Continuation of Care Request Form
• Emergency Room Review Form
• HIPAA Authorization for Disclosure of Health Information — authorizes AmeriHealth to release member’s health information
• HIPAA Personal Representative Form — appoints another person as member’s personal representative
• LTAC Precertification Form
• Member Consent for Financial Responsibility for Unreferred/Non-covered Services Form
• Member Consent for Provider to File an Appeal on my Behalf with Health Insurance Plan
• Off Cycle Concierge Attestation Form
• Off Cycle Concierge Questionnaire
• Overpayment Refund Form
• PCP to Behavioral Health Provider Communication Form
• Post-Acute Facility Admission Guide
• Provider Change Form
• Provider Network Services Inquiry Request
• Request to Move Member from PCP to LTC PCP Panel
• Request to Update Procedure Code(s) on an Existing Authorization Form
• Surgical Team (Modifier -66) Documentation Form

Peer-to-peer requests

The peer-to-peer process streamlines workflows, improves cost-efficiencies, and complies with accreditation requirements. To participate in the peer-to-peer process, please complete the Peer-to-Peer Request form.

Registered Nurse Health Coach requests

If you are interested in having a registered nurse Health Coach work with your Pennsylvania patients, please complete a physician referral form or contact us at 1-800-313-8628.

Prior authorizations for medications

A request form must be completed for all medications requiring prior authorization. Please submit the applicable Prior Authorization Forms for prescription drugs.

Member eligibility and claim status

To verify member eligibility or check the status of a claim, please use the PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal or call 1-800-275-2583 (PA) to access the Provider Automated System.

For all other questions and inquiries, call Customer Service at 1-800-275-2583 (PA).