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 |