Forms and Resources for Providers

Search for forms, drug lists, manuals and more.

Document	Key Words
Limited Distribution Specialty Drug List	covered prescriptions formulary drugs medications accredo acredo
Allergy Benefit Extension Request
Appendix B: Laboratory Guideline to Approved In-Office Laboratory Tests	provider manual clia tests in office in-office labs
Benefit Fund Appeal Representation Authorization Form	claims appeals denial designate designation grant
Cardiac/Pulmonary Rehabilitation Request
CareAllies Initial Pre-Certification Request	care allies pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
CareContinuum Medical Drug Benefit Management Program	care continuum
Medical Management for Chiropractic Services - Quick Reference Contact Sheet
Medical Claim Reconsideration Request	claims appeals
eviCore Codes Requiring Authorization	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization out patients outpatients precertification certification pre-certification authorize authorizing
Codes Under eviCore Radiation Therapy Review Program	evi 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 Program	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Co-Pays for Greater New York Members	what'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
eviCore Contrast Agents and Radiopharmaceutical	evi 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 Codes	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Laboratory Management Program FAQs	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing frequently asked questions
eviCore Medical Oncology Primary and Supportive Drug List	covered 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 Review Program FAQs	evi 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 Lab Management Quick Reference Guide	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing laboratory laboratory
eviCore Radiation Therapy Clinical and Coding Guidelines	evicore evi core carecore care
eviCore Radiation Therapy Clinical Documentation Requirements	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
eviCore Radiation Therapy Management Program Quick Reference Guide	evi 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 FAQs	evi 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 Codes	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing evi core carecore care
eviCore Radiology Review Management Program	evi 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 FAQs	evi 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 Law	evi core carecore care frequently asked questions
Focus DRG Validation Program	Readmission Review Programs
Request for Home Oxygen Authorization	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
HomeCare, Certain Outpatient, DME and Rx Services	durable 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 Claim Reconsideration Request Form	HCPCS icd10 icd-10 cpt drg appeals claims
CareAllies Medical Management for Hospital Services - Quick Reference Contact Sheet	care allies
IRS Form W-9	w9 taxes
Laboratory Management Clinical Policy Manual	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
CareContinuum Medical Drug Benefit Management Program Specialty List	covered 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 Services and/or Ambulatory Surgical Procedures that Require Pre-Authorization	out patients outpatients pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Preferred Drug List (PDL)	covered prescriptions formulary drugs medications prefered preferred
Prescription Request for Authorization	covered prescriptions medications drugs pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Provider Demographic Information Change Request Form Guide	how 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 Form	how do i we to change update add my our Billing service address? Business? Name? tax id tin w9 w-9 npi
Provider Manual	instructions help
Provider Quick Reference Guide	instructions help policy cheet sheet
Provider Recruitment Form	how do I we sign up
Radiation Therapy Prior Authorization and Claims Studio Procedure Codes	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Radiation Therapy Tools and Criteria	evi 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 List	Privileging 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
The 90-Day Rx Solution	90 day covered prescriptions drugs medications
NYC PICA Drug List (for LPN Members and NYC municipal employees only)	covered prescriptions formulary drugs medications prefered preferred new york city lpn licensed practical nurses welfare fund
90-Day Rx Solution Maintenance Drug Access Program Waiver Request Form	90 day maintenance covered prescriptions formulary drugs medications prefered preferred exception prior authuthorization priorauthorization prior-authorization preauthorization pre-authorization
Utilization Management Master Drug List	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization outpatients precertification certification pre-certification authorize authorizing um accredo acredo pica nyc employees new york city qty quantity limited express scripts expressscripts evicore evi core cancer oncology split fill step therapy client
Pharmacist Authority to Administer Vaccines by State	vaccinations vacines vacinations
Prescription Claims Reimbursement Form	covered prescriptions claims formulary drugs medications prefered preferred new york city lpn licensed practical nurses welfare fund hmo plans retail pharmacies pharmacy
Transcranial Magnetic Stimulation (TMS) Pre-Authorization	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization out patients outpatients precertification certification pre-certification authorize authorizing
PT/OT/ST & Acupuncture Request	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing
Balance Billing Fee Negotiation Authorization Form	balance billing fee authorization negotiation provider participating provider directory eob
Care Management Program Quick Reference Guide	evi core carecore care pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization precertification certification pre-certification authorize authorizing quick reference guide frequently asked questions
Prior Authorization for Intensive Outpatient or Partial Hospitalization Programs	pre prior authorization preauthorization priorauthorization pre-authorization prior-authorization authorize authorizing member assistance concurrent review intensive outpatient program partial hospitalization