Documents & Forms Center

Medicare, Providers

Long Term Acute Care Hospitalization MCR

PDF icon Long-Term-Acute-Care-Hospitalization-MCR.pdf

Providers

Magnetic Resonance Imaging (MRI) Cervical Spine Com

PDF icon MRI-Cervical-Spine-Criteria-Outpatient-COMM.pdf

Providers

Magnetic Resonance Imaging (MRI) Lumbar Spine Com

PDF icon MRI-Lumbar-Spine-Criteria-Outpatient-COMM.pdf

Management of High Blood Pressure Guidelines

PDF icon Management-of-High-Blood-Pressure-guidelines-2022.pdf

Members, Providers

Medical Services That Require Prior Auth

PDF icon MEDICAL-SERVICES-THAT-REQUIRE-PRIOR-AUTHORIZATION-1-31-23.pdf

Medicare

Medicare Agent Flyer

PDF icon H5938_DP1478_C2019 Agent Flyer for Website.pdf

Medicare

Medicare FAQs for web

PDF icon Medicare FAQs for web.pdf

Medicare Fraud and Abuse 102016

PDF icon Medicare Fraud and Abuse 102016.pdf

Medicare

Medicare Made Easy

PDF icon 2020.09.001 2021 Medicare Made Easy FINAL.pdf

Medicare

Medicare Part D Transition Policy

PDF icon Prime Medicare Transition Policy.pdf

Medicare, Members

Medicare Prescription Drug Reimbursement Request

PDF icon MCR Prescription Drug Request for Reimbursement.pdf

Medication Prior Authorization Request

PDF icon Universal Prior Authorization Form.pdf

Providers

Medications Obtained Through the Medical Benefit

PDF icon J-Code-Med-only-update-website-04-24.pdf

Member Services FAQs for web

PDF icon Member Services FAQs for web.pdf

Agents, Employers, Members

Member Status Change Form

PDF icon Member Status Change Form 2020.pdf

Medicare

MTMP Personal Medication List

PDF icon MTMP Personal Medication List.pdf

Nations OTC Catalog Large Print

PDF icon OTC-Catalog-CapitalHealthPlan-List-2022-18PT.pdf

New Member Checklist

Members

Non- Group Conversion (NGC-B) $15/$30/$50

PDF icon Non-GroupConversionNGC-B01-01-21.pdf

Non- Group Conversion (NGC-B) $15/$30/$50

PDF icon Non- Group Conversion (NGC-B) 1-1-24.pdf

Non- Group Conversion (NGC-B) 1-1-22

PDF icon Non- Group Conversion (NGC-B) 1-1-22.pdf

Members

Non-Group Conversion

PDF icon Non-Group Conversion.pdf

Non-Group Conversion NGC B-1-1-22

PDF icon non-group-conversion-ngc-b-1-1-22.pdf

Members

Non-Medicare Appointment of Representation Form

PDF icon COM AOR form_3.11.15.pdf