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Services Requiring Prior Authorization
This document is intended only to provide information related to which CPT/HCPCs codes require prior authorization. It does not indicate/list codes which may be excluded from coverage or not covered for other reasons. In addition, inclusion on this list indicates, if covered the code would require prior authorization for coverage.
2025 $0 Out-of-Pocket Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2023 Employer Application For Group
2023 Individual & Small Groups Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2024 $0 Out-of-Pocket Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
2024 Employer Application For Group
2024 Individual & Small Groups Prescription Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
Add New Provider Form
Use this form to add a new provider to your already contracted group.
AMA Guide for No Surprises Act Disputes
Appeal Form
Behavioral Health Provider Policies
Residential Treatment Center (RTC) Requirements Policy
Behavioral Health/Substance Request Form
Broker Media Kit
Training for Brokers.
Claim Denial: External Review Request Form
If you appeal a claim and were still denied you can request a review of the circumstances. In most cases, before filing an external review, you must first exhaust your internal grievance and appeal rights.
Incapacitation Review (Claim Denial)
If you appeal a claim and were still denied you can request a review of the circumstances. In most cases, before filing an external review, you must first exhaust your internal grievance and appeal rights.
Consent Form
Download: In Network Rates (.zip)
Download: Out of Network Rates (.zip)
Practice/Provider Update Form
Use this form to update provider information, add or change a practice location, or adjust billing information.
Employee Census Form (Excel Download)
Use to upload through Broker Portal for instant quote.
Formulary Change Notice
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
Formulary Exception Request Form
To request a drug formulary not listed on MHC Formulary List. To view formulary list and complete pharmacy details View Pharmacy Page.
Home Health Care Request Form
Fax this completed form to 559-243-7012.
Hospice Care Request Form
Individual Member Monthly Premium Withdrawal Form
Authorization Agreement for ACH Debit/Change Method of Premium Payment. To authorize a monthly ACH debit or to request a change in the method of premium payment, please indicate which billing method you are changing to and complete all applicable information. You will then need to sign, date and return this form. See the bottom of this form for details
Large Group Preferred Drug List
Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.
Medical Claim Form
The best way to manage claims is in the Member Portal.
Submitting Additional Documentation
Did you receive a denial code (252 and/or M127) for missing medical documentation (MDOC)? Please only use this form in response to 252 and/or M127 denial codes.
Complaint Form
Member Welcome Guide
Your definitive guide to your new health plan.
MRI Criteria Guidelines
myCareHC Provider User Guide
This user guide outlines the process of registering for your myCareHC Provider account and accessing the precertification tool.
No Surprises Act Dispute Form
Non-Formulary Drug Coverage Policy
To view formulary list and complete pharmacy details View Pharmacy Page.
Open Negotiation Notice Instructions (Zelis)
The Open Negotiation Notice must be submitted to [email protected].
Organizational Provider Credentialing Application
Prescription Claim Form
The best way to manage claims is in the Member Portal.
Preventive Care Guidebook
Learn about your free preventive health care benefits.
Prior Authorization Form PDF Version
The best way to submit prior authorization requests is through the Provider Portal.
Prior Authorization Form: Medical Pharmacy
For Specialty Drug Requests. Downloadable PDF Version suitable for faxing. For more details and to view online pharmacy prior authorization version View Pharmacy Page.
Provider Manual
Our Provider Manual is your definitive guide to working with the Co-Op.
Receiving Funds & Setting up EFT
We must have a W-9 on file before we can make any payments to you. If we do not have a direct deposit set up for your group, we will send a paper check.
Release Health Info to Someone Else
Authorization for Disclosure of Protected Health Information
Remove a Provider: Term Request Form
Use this form to remove a provider that has left the group.
Report Changes Member Form
Any life changes must be reported to your policy to ensure claims are processed properly. If you don’t report life changes, you may be at risk of claim denials.
Request Fee for Waiver (Wyoming)
Retail Drugs Prior Authorization & Exception Forms
Coverage Policies
Retail Pharmacy Appeal Form
Skilled Nursing Facility & Acute Rehab Request Form
Authorization Request for SNF, Acute Rehab and LTAC
Utilization Mgmt. Medical Policies
We would be happy to provide you with a copy of the criteria we use to make utilization management decisions. Contact the UM team for more info: 833-412-4144. You may also email your request for criteria to [email protected]
Zelis Bill Review for Claim Appeal Form
Zelis Claim Appeal Submittal Form Bill Review Complete all information requested below and fax or email with a copy of complete medical records, itemized bills and a copy of the HCFA-1500 or UB-04 to (908) 658-3511 or [email protected].
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