Health Care Provider Forms



Claim Review

Note: Review each form to determine the appropriate form to use


  • Additional Information Form
  • Claim Review Form
  • Corrected Claim Form
Coordination of Benefits Online Questionnaire
Interactive Questionnaire 
Dependent Student Medical Leave Certification Form  
Hemophilia Referral Fax  Interactive
Hospital Coverage Letter  Interactive
Medicare Advantage Annual Wellness Visit guide   Interactive
Medicare Advantage Annual Wellness Visit Form   Interactive
Out-of-Network — Enrollee Notification Form for Regulated Business (Use this form if "TDI" is on member's ID card) PDF Document  
Out-of-Network — Enrollee Notification Form for Non-Regulated Business (Use this form if "TDI” is not on member's ID card) PDF Document  
PPO Notification for non pre-cert surgeries per Texas Administrative Code 3.3703   
Predetermination Request  Fillable
Prior Authorization   
Provider Refund  Fillable
Room Rate Update Notification   
Urine Drug Testing Form for Out-of-Network Providers Interactive
Verification Request Interactive 

Electronic Payment Solutions

FormDescription Learn more about third-party links

Save time and enroll online for Electronic Funds Transfer and Electronic Remittance Advice.

Electronic Funds Transmission (EFT)  Fillable
Electronic Remittance Advice (ERA)  Fillable

Medical Policy Forms (Note: May be used as a supplement to medical record documentation)

Bariatric Surgery  Interactive
Botulinum Toxin  Interactive
Cranial Remolding Orthosis (CRO) Device  Interactive
Erythropoiesis-Stimulating Agents (ESAs)  Fillable
Genetic Testing  Instructions 
Growth Hormone  Interactive
Hyperbaric Oxygen (HBO) Pressurization  Interactive
Immunoglobulin Therapy  Interactive
Oncotype DX  Interactive
Remicade  Interactive
Varicose Vein Management  Interactive
Wheelchair Medical Necessity and Home Evaluation Verification  Interactive

Behavioral Health


Applied Behavior Analysis (ABA) forms:

Coordination of Care   
Electroconvulsive Therapy (ECT) Request   
Focused Outpatient Management Program   
Intensive Outpatient Program (IOP) Request   
Psychological/Neuropsychological Testing Request   
Repetitive Transcranial Magnetic Stimulation (rTMS)    


PrimeMail New Prescription Fax Order   
Prime Specialty Pharmacy Fax Form   
Quantity Limit Override Request   
Topical Verapamil Override Request