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 Provider Resources

New Outpatient Therapy Guidelines
Physical and Occupational Therapy Guidelines
Speech Therapy Guidelines
Vision Therapy Guidelines

Prior Approval/Prior Authorization Forms

Prior Approval for Out of State/Out of Network Services
Precertification for Services
Orthodontia Precertification Form
 
Medical Home Program 
Medical Home Selection Form (for members)

Prescription Drug Plan
Current Preferred Drug List 
CVS Caremark Prescription Reimbursement Claim Form
Prior Approval Request for Prescriptions
Prior Approval Request Form for ADD Medications
Prior Approval Request Form for Antipsychotics Medications, and Guidelines

Immunization Resources
CPT Codes for Immunizations
Immunization Schedule for Ages 0-6 years
Immunization Schedule for Ages 7-18 years

Preventative Care
Dental Care Flyer
Vision Care Flyer
Well-Child Exam Flyer
Child Development Flyer
Hearing Screening Flyer

Healthcheck Forms
Healthcheck Provider Manual and Forms
Kindergarten Screening Document

Dental Information
Dental Provider Guide
Dental Procedure Codes (2019)

Benefit Resources & Reimbursement
Reimbursement for Developmental Screenings

Applied Behavioral Analysis
Policy: Applied Behavior Analysis, Effective January 2019
2019 Applied Behavior Analysis Allowable Services and Coding Guide
Minimum Training Standards: Front Line ABA Staff

Required Documents for Pre-Authorization Requests:
Applied Behavior Analysis (ABA) Services Pre-Authorization Request Form (Cover Sheet to PA Request)
Applied Behavior Analysis (ABA) Prior Authorization Units of Service Request Form
ABA Statement of Assurance