Documents & Forms Center

Medicare, Providers

Anesthesia and Facility Charges for Dental Services MCR

PDF icon Anesthesia and Facility MCR.pdf

Providers

Applied Behavioral Analysis (ABA) Services Com

PDF icon Applied Behavior Analysis (ABA) Services COM.pdf

Medicare, Providers

Blood Glucose Monitor and Testing Supplies Using the Medical Benefit

PDF icon Blood Glucose Monitor and Testing Supplies_Final_033021.pdf

Members, Providers

Clinical Guideline - Secondary Prevention for Patients with Atherosclerotic Vascular Disease

PDF icon Vascular Clinical Guidelines 2019.pdf

Members, Providers

Clinical Guideline - Secondary Prevention for Patients with Atherosclerotic Vascular Disease 2021

PDF icon Vascular Clinical Guidelines 2021.pdf

Members, Providers

Clinical Guidelines - Diabetes Care

PDF icon 2019 Diabetes Clinical Practice Guideline 3.12.19.pdf

Members, Providers

Clinical Guidelines - Diabetes Care 2021

PDF icon 2021 Diabetes Clinical Practice Guideline.pdf

Providers

Colonoscopies Com

PDF icon Colonoscopies- COM.pdf

Agents, Employers, Medicare, Members, Providers

Covid OTC Test Kits

PDF icon COVID-OTC Test Kits.pdf

Agents, Employers, Members, Providers

Glossary of Health Coverage and Medical Terms

PDF icon Glossary of Health Coverage and Medical Terms.pdf

Agents, Employers, Medicare, Members, Providers

Health and Fitness Reimbursement Form

PDF icon Fitness Reimbursement Form 040820 FILLABLE.pdf

Medicare, Providers

Implantable Hearing Devices MCR

PDF icon Implantable Hearing Devices MCR.pdf

Providers

Instructions for completing Prior Authorization Form

PDF icon Instructions for completing Prior Authorization Form.pdf

Providers

J Code Med Only Update

PDF icon J Code Med only update website 3 30 21.pdf

Providers

J Code Med Only Update 2022

PDF icon J-Code-Med-only-update-website-04-22.pdf

Providers

Long Term Acute Care Hospitalization Com

PDF icon Long Term Acute Care Hospitalization COM.pdf

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 COM.pdf

Providers

Magnetic Resonance Imaging (MRI) Lumbar Spine Com

PDF icon MRI Lumbar Spine Criteria Outpatient COM.pdf

Members, Providers

Medical Services That Require Prior Auth

PDF icon MEDICAL SERVICES THAT REQUIRE PRIOR AUTHORIZATION 7-26-21.pdf

Providers

Medications Obtained Through the Medical Benefit

PDF icon j-code-med-only-update-website-12-18-18.pdf

Providers

Patient Headache Diary

PDF icon MMS-HEADACHE DIARY 33021.pdf

Providers

Pediatric Health Assessment

PDF icon Pediatric Health Assessment.pdf

Providers

Perinatal Care

PDF icon Perinatal Care.pdf