Forms and Resources for Providers

 

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DocumentKey Words
Accredo Specialty Drug List (Limited Distribution Network)covered prescriptions formulary drugs medications
Accredo Specialty Drug Listcovered prescriptions formulary drugs medications
Allergy Benefit Extension Request
Appendix B – Laboratory Guidelinesprovider manual clia tests in office in-office
Cardiac, Pulmonary Rehabilitation Request
CareAllies Initial Pre-Certification Requestcare allies pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
CareContinuum Medical Benefit Management Programcare continuum
Chiropractic Services
Claim Reconsideration Requestclaims
Codes Requiring Prior Authorizationpre prior authorization preauthorization priorauthorization pre-authorization prior-authorization out patients outpatients precertification certification pre-certification authorize authorizing
Codes Under eviCore Radiation Therapy Review Programevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Complete Code List under eviCore Laboratory Management Programevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Co-Pays for Greater New York Memberswhat's what is the gny copays copayments co-payments for a primary care office visits appointments general family internal medicine practitioners pediatricians OB/GYNs geriatricians adolescent medicine providers prescriptions drugs medications preventive services
Drug Quantity Management (DQM) Listcovered prescriptions formulary drugs medications
Drugs Requiring Prior Authorizationcovered prescriptions formulary drugs medications pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
EmblemHealth Preferred Dental Transition of Care Formdental dentistry Emblem Health
eviCore Contrast Agents and Radiopharmaceuticalevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Radiology and Cardiology Diagnostic Claims Studio Procedure Codesevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Laboratory Management Program FAQsevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing frequently asked questions
eviCore Medical Oncology Drug Listcovered prescriptions medications evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing oncology primary and supportive therapies drugs list clinical pathway precertification certification pre-certification reference document
eviCore Medical Oncology Management Programevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Medical Oncology Review Program FAQsevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing quick reference guide frequently asked questions
eviCore Quick Reference Guideevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Radiation Therapy Clinical Policy Manualevicore evi core carecore care
eviCore Radiation Therapy Clinical Documentation Requirementsevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Radiation Therapy Management Programevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing quick reference guide
eviCore Radiation Therapy Review Program FAQsevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing frequently asked questions
eviCore Radiology and Cardiology Diagnostic Services Prior Authorization Procedure Codespre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing evi core carecore care
eviCore Radiology Review Management Programevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing quick reference guide
eviCore Radiology Review Program FAQsevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing frequently asked questions
FAQs: 2013 Behavioral Health Code Changes and the Mental Health Parity Lawevi core carecore care frequently asked questions
Focus DRG Validation Program
Home Oxygen Therapy Request for Authorizationpre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
HomeCare, Certain Outpatient, DME and Rx Servicesdurable medical equipment drugs covered prescriptions home care out patients outpatients medications pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Hospital Claims Reconsideration FormHCPCS icd10 icd-10 cpt drg appeal
Hospital Services
IRS Form W-9w9 taxes
Laboratory Management Clinical Policy Manualevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Letter to Members Regarding Emdeon
Medical Benefit Management Program Specialty Drug Listcovered prescriptions formulary drugs medications ExpressPAth express path carecontinuum care continuum pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Outpatient and Home Care Servicesout patients outpatients homecare
Outpatient Services and/or Ambulatory Surgical Proceduresout patients outpatients
Preferred Drug List (PDL)covered prescriptions formulary drugs medications prefered preferred
Prescription Request for Authorizationcovered prescriptions medications drugs pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Provider Demographic Information Change Request Form Guidehow do i we to change update add my our Billing service address? Business? Name? tax id tin w9 w-9 npi instructions help guide guidance
Provider Demographic Information Change Request Formhow do i we to change update add my our Billing service address? Business? Name? tax id tin w9 w-9 npi
Provider Manualinstructions help
Provider Quick Reference Guideinstructions help policy cheet sheet
Provider Recruitment form how do I we sign up
PT/OT/ST Benefit Extensionphysical occupational step therapy
Radiation Therapy Prior Authorization and Claims Studio Procedure Codesevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Radiation Therapy Tools and Criteriaevi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Radiology Criteria (eviCore healthcare’s evidence-based clinical guidelines)evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing policy
Radiology Privileging ListPrivileging standards by specialty cpt codes
Service/Equipment Request for Authorization pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Step Therapy Drug Listcovered prescriptions formulary drugs medications
The 90-Day Rx Solution90 day covered prescriptions drugs medications