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Please use the links below to download the following forms as PDF files:

Request for Claim Review Reconsideration Form
The Request for Claim Review / Reconsideration Form is utilized by participating providers to present claim disputes directly to the attention of the Provider Relations Department. All information on the form must be completed to extent required. Claims Reviews / Reconsiderations Forms filed past the (120)  days from the date on the corresponding claim’s Remittance Advice will be considered as a late filing and will not be processed.

Notice of Resolution of Claim Review Reconsideration
Participating Providers are communicated the results of claim dispute reviews through a Notice of Resolution of Claims Review / Reconsideration Form within 30 business days from the receipt date of the claim dispute. The results of any adverse claims disputes reviews are contestable within 15 business days from the receipt of the Notice of Resolution of Claims Review / Reconsideration Form and the results are considered final post-secondary review.

Request for Prior Authorization of Benefits / Services Form
Certain benefits and services require prior authorization; Prior authorization must be obtained from the Plan by the requesting Provider either on-line on the Provider Portal or using the Request for Prior Authorization of Benefits / Services Form. All informational elements must be completed legibly to the extent required to allow for timely processing.

Expedited  or Urgent requests for prior authorization attests that the PCP certifies that by applying the review time frame for standard authorization requests, the standard review time may seriously jeopardize the member’s life, health, or ability to regain maximum function.  For verificationt of those benefits or services requiring prior authorization, provider must verify the member’s eligibility and benefits online or by calling Provider Relations at (305) 422 – 9300 and selecting, Option 3.

Part D – Physician – Coverage Determination Form

A coverage determination is necessary when a formulary medication requires a Prior Authorization, Step Therapy and/or Quantity Limit.  Exceptions, such as Tiering exceptions and Formulary exceptions, also require coverage determination. A tiering exception is when you believe a member should get a drug at a lower cost share. A formulary exception is when you believe a member needs a drug that is not on the plan’s formulary. All exception requests must be supported by a statement by the prescribing physician.  Standard Coverage Determinations will be made within 72 hours. Expedited Coverage Determinations will be made within 24 hours.

Provider Compliance Requirements Attestation Form

The Doctors HealthCare Plans, Inc. Provider Compliance Requirements Attestation form is completed by Participating Providers upon conclusion of the online interactive web-based compliance training modules on the CMS Medicare Learning Network (MLN).  Submission of the form attests to the provider’s completion of the General Compliance Training and Fraud, Waste and Abuse training.   Completed forms must be submitted to the Department of Provider Relations for record keeping.

SNP MOC Training Attestation and Evaluation Forms

Providers are required to undergo SNP Model of Care Training. This training provides an overview of SNPs and the responsibilities physicians and other participating health care providers have for their SNP patients.

H4140_PRforms_C
Last Updated: 11/14/18

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