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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.

2026 $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.

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, Substance Treatment, Skilled Nursing & Residential Care Authorization Form

Broker Media Kit

Training for Brokers.

Claim Denial: Incapacitation Review

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.

Claim Denial: MT 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.

Claim Denial: WY 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.

CMS 1500 Claim Form

Submit this completed form by fax to 800-781-6260 (preferred) or by mail to Mountain Health Co-Op, PO Box 30311,Salt Lake City, UT 84130.

Consent Form

Coordination of Benefits Form

If you have coverage through more than one health plan, use this form to establish the order in which each plan will receive, process, and pay your claims.

Employee Census Form (Excel Download)

Use to upload through Broker Portal for instant quote.

Formulary Change Notice, December 2024

Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.

Formulary Change Notice, December 2025

Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.

Formulary Change Notice, February 2026

Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.

Formulary Change Notice, May 2025

Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.

Formulary Change Notice, May 2026

Downloadable PDF Version of Pharmacy Details. For online pharmacy search links and complete pharmacy details View Pharmacy Page.

Formulary Change Notice, October 2025

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

Idaho Health Insurance Basics

Learn more about what to look for when you're shopping for health insurance.

Idaho Health Insurance Basics (Spanish)

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

Submit this completed form to the fax number or the mailing address listed on the document.

Complaint Form

Member Welcome Guide

Your definitive guide to your new health plan.

Montana Health Insurance Basics

Learn more about what to look for when you're shopping for health insurance.

Montana Health Insurance Basics (Spanish)

Learn more about what to look for when you're shopping for health insurance.

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].

Organization Credentialing Application

Out of Network Waiver Form

Use this form to request out-of-network care.

Practice/Provider Update Form

Use this form to update provider information, add or change a practice location, or adjust billing information.

Prescription Claim Form

The best way to manage claims is in the Member Portal.

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 single provider that has left the group. For existing group contract questions, please contact [email protected].

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

Skilled Nursing Facility & Acute Rehab Request Form

Authorization Request for SNF, Acute Rehab and LTAC

Transition and Continuity of Care Waiver Form

This secure form should be used to request Transition of Care (TOC) or Continuity of Care (COC) if your Provider is no longer contracting with Mountain Health Co-Op and you believe you are eligible for Transition of Care benefits. It can be completed by the member, but requires a provider signature.

UB04 Claim Form

Submit this completed form by fax to 800-781-6260 (preferred) or by mail to Mountain Health Co-Op, PO Box 30311,Salt Lake City, UT 84130.

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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