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Resources & Tools

Provider Online Forms

If you need a copy of a particular form, ConnectiCare's Online Form Resource can save you time. To obtain a copy of a specific form, please click on the form by name below. A description and directions for use will appear.

All forms are in PDF format. The freely available Adobe Acrobat reader is required to view and print PDF files.

All forms are the exclusive property of ConnectiCare, or used by ConnectiCare with permission, and protected by copyright. All forms are to be used solely for business with ConnectiCare.

Claims Payment:

Medicare Claim Resubmission Request Form
Medicare Medicare Claim Submission for Unlisted Procedure Codes Form
Medicare Provider Appeal Request Form
Medicare Standard Provider Refund Form

Health Management:

Health Screening Checklist
Medication List
Problem List
Adult Patient Summary
Asthma Control Plan

Medical Pre-Authorization:

Clinical Review Pre-Authorization Request Form
Medicare Home Health Care Pre-Authorization Request Form
Medicare IV Therapy Authorization Request Form
Medicare Out-of-Network Clinical Review Pre-Authorization Request Form

Pharmacy Pre-Authorization:

Addition to Formulary Request Form
Non FDA Approved Drug Use and/or Dose Request Form
Medicare Pharmacy Pre-authorization Form: Physician Administered Drugs

Other Forms:

Request For Medicare Prescription Drug Coverage Determination
Medicare Reconsideration Request Form
Advance Health Care Directives
Credentialing Data Form
Credentialing Data Form for Outpatient Rehabilitation Providers
Recredentialing Verification Form
Supply Reorder Form
W-9 Request

Form

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Directions for Use

Medicare Claim Resubmission Request Form

(formerly Adjustment/Corrected Claim Request Form)

Use this form to provide us with the required information to process your request for an adjusted or corrected claim.

Fill in the appropriate information
Print the form
Mail the completed form to ConnectiCare, Attn: Claim Resubmission, PO Box 4000, Farmington, CT. 06032-3124.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:30 a.m. - 5:00 p.m., Eastern Time

Form

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Directions for Use

Medicare Claim Submission for Unlisted Procedure Codes

Use this form to support the use of an unlisted procedure or service code. This information will be used to determine appropriate payment and claim adjudication in conjunction with the member's benefit plan.

Fill in the form online.
Print the completed form.
Mail the completed form to ConnectiCare, Attn: Claims Department, P.O. Box 4000, Farmington, CT 06034-4000.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:30 a.m. - 5:00 p.m., Eastern Time.

Form

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Directions for Use

Medicare Provider Appeal Request Form

If you would like to request reconsideration of a claim that was denied for administrative purposes (e.g., filing limit, coding edits).

Fill in the form online.
Print the completed form.
Fax the completed form to the Provider Appeals Coordinator (860) 674-7035 or mail to ConnectiCare, Attn: Provider Appeals Coordinator, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:30 a.m. - 5:00 p.m., Eastern Time.

Form

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Directions for Use

Medicare Standard Provider Refund Form

If you need to make a refund back to ConnectiCare due to an overpayment.

Print the form
Fill out the appropriate information
Mail to ConnectiCare, Inc., P.O. Box 32153, Hartford, CT 06150-2153
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:30 a.m. - 5:00 p.m., Eastern time

Form

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Directions for Use

Health Screening Checklist

To document information for patient files.

Print the form.
Fill out appropriate information and place in the patient’s file.

Form

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Directions for Use

Medication List

To document information for patient files.

Print the form.
Fill out appropriate information and place in the patient's file.

Form

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Directions for Use

Problem List

To document information for patient files.

Print the form.
Fill out appropriate information and place in the patient's file.

Form

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Directions for Use

Adult Patient Summary

To document information for patient files.

Print the form.
Fill out appropriate information and place in the patient's file.

Form

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Directions for Use

Asthma Control Plan

If you are seeking to design an Asthma Treatment Plan with your patient.

Print the form.
Use for developing an Asthma Treatment Plan.
Have your patient keep the asthma plan available for easy reference.
If your patient would like additional information about asthma, or would like to enroll in a free Asthma Education class where they will receive a peak flow meter, a video, and educational materials, please have them call 1-800-390-3522.
If you have any questions, call ConnectiCare’s Health Management Programs at 1-800-390-3522, Monday through Friday 8:00 a.m. – 4:30 p.m., Eastern Time.

Form

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Directions for Use

Clinical Review Pre-Authorization Request Form

If you are seeking to obtain authorization of services or procedures included under ConnectiCare's pre-authoriztion requirements.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare's Clinical Review at 1-866-706-6929. Please use a cover sheet to protect transmission of PHI.
If you have any questions, call Provider Services at 1-877-224-8230.

Form

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Directions for Use

Medicare IV Therapy Authorization Request Form

If you are seeking to obtain authorization of IV therapy.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-866-706-6929. Please use a cover sheet to protect transmission of PHI.
If you have any questions, call Provider Services at 1-877-224-8230.

Form

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Directions for Use

Medicare Home Health Care Authorization Pre-Authorization Request Form

If you are seeking to obtain authorization of home health care.

Fill in the form online.
Print the completed form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-866-706-6929. Please use a cover sheet to protect transmission of PHI. If you have any questions, call Provider Services at 1-877-224-8230.

Form

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Directions for Use

Medicare Out-of-Network Clinical Review Pre-Authorization Request Form

If you are seeking to obtain authorization of services or procedures by out-of-network providers.

Fill in the form online.
Print the form.
Fax the completed form and medical documentation to ConnectiCare’s Clinical Review at 1-866-706-6929. Please use a cover sheet to protect transmission of PHI. If you have any questions, call Provider Services at 1-877-224-8230.

Form

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Pharmacy: Non FDA Approved Drug

Use this form when seeking authorization to write a prescription for a drug for off-label use or off-dosage.

Print the form.
Fill in the appropriate information.
Mail the completed form to ConnectiCare, Pharmacy Services, Attn: Clinical Department, 55 Water Street, New York, NY 10041 or, fax to ConnectiCare Clinical Pharmacy Services at 1-877-300-9695.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:00 a.m. - 5:00 p.m., Eastern Time.

Form

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Pharmacy: Addition to Formulary

Use this form to request that a drug be added to the ConnectiCare formulary.

Print the form.
Fill in the appropriate information.
Mail the completed form to ConnectiCare, Pharmacy Services, Attn: Clinical Department, 55 Water Street, New York, NY 10041 or, fax to ConnectiCare Clinical Pharmacy Services at 1-877-300-9695.
If you have any questions, call Provider Services at 1-877-224-8230, Monday through Friday 8:30 a.m. - 5:00 p.m., Eastern Time.

Form

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Medicare Pharmacy Pre-authorization Form: Physician Administered Drugs

If you are seeking to obtain authorization for a physician administered drugs (e.g., injectable drugs).

Print or save the form.
Fill in the appropriate information.
Fax the completed form to Pharmacy Services (860) 674-2851 or toll free (800) 249-1367 or mail to ConnectiCare, Attn: Pharmacy Services, 175 Scott Swamp Road, Farmington, CT. 06032-3124.
If you have any questions, call ConnectiCare’s Member Services Dept. at 1-800-251-7722, 8:00 a.m. to 6:00 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

Form

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Advance Health Care Directives

If you wish to provide your patients with information on how they may go about obtaining an advance directives.

Print the form.

Form	Use this form...	Directions for Use
Request For Medicare Prescription Drug Coverage Determination Form	Initial coverage determination means the Plan's decision as to whether to provide or pay for a Part D drug including determinations on medical necessity, drugs not on the formulary, drugs furnished by an out-of-network pharmacy, drugs that are benefit exclusions, drugs requested as exceptions, and decisions on cost-sharing amounts. You may contact a ConnectiCare Member Service Advocate concerning your prescriptions or any questions you may have or alternatively, utilize the form provided on the ConnectiCare web site for a Prescription Drug Coverage Determination.	Please send your ConnectiCare Medicare Prescription Drug Coverage Determination form to: FAX: 1-877-300-9695 or to ConnectiCare Pharmacy Services / Clinical Review, P.O. Box 1520 JAF Station, New York, NY 10116-1520.

Form	Use this form...	Directions for Use
Medicare Reconsideration Request Form	Request For Medicare Prescription Drug Coverage Determination If you have requested one of the above items and your request was not granted, you may appeal this item by following the instructions in your denial letter (either by writing a letter or by using the attached form).	For an Expedited Appeal: You or your appointed representative should contact us by telephone or fax at the numbers below: Phone: 1-866-829-8180 For a Standard Appeal: You or your appointed representative should mail or deliver your written appeal request to the address(es) below: Correspondence: ConnectiCare Grievance & Appeal Department PO Box 2786 JAF Station 10116–2786 Walk-in: ConnectiCare Member Service 175 Scott Swamp Road Farmington, CT 06032

Form

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Credentialing Data Form

If you are looking to submit an application to participate within the ConnectiCare network of participating health care providers.

If you are an Individual Outpatient Rehabilitation Provider, please use the Credentialing Data Form for Outpatient Rehabilitation Providers.

Fill in the form online.
Print the completed form.
Fax the completed form, along with a W-9 form, to Network Operations at (860) 674-2849 or mail to ConnectiCare, Attn: Network Operations, 175 Scott Swamp Road, Farmington, CT 06032-3124.
If you have any questions, call ConnectiCare’s Provider Services Dept. at 1-800-828-3407, 8:30 a.m. to 5:00 p.m. Monday through Thursday, and 9:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

Form

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Directions for Use

Credentialing Data Form for Outpatient Rehabilitation Providers

If you are looking to submit an application to participate within the ConnectiCare network of participating health care providers as an outpatient rehabilitation provider.

Print the form.
Fill in the appropriate information.
Fax the completed form, along with a W-9 form, to Network Operations at (860) 674-2849 or mail to ConnectiCare, Attn: Network Operations, 175 Scott Swamp Road, Farmington, CT 06032-3124.
If you have any questions, call ConnectiCare’s Provider Services Dept. at 1-800-828-3407, 8:30 a.m. to 5:00 p.m. Monday through Thursday, and 9:00 a.m. to 5:00 p.m. on Fridays, Eastern Time.

Form

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Recredentialing Verification Form

If you are looking to submit a recredentialing verification form to continue participating within the ConnectiCare network of participating health care providers and are unable to access CAQH (preferred method).

If you would like to complete a CAQH application, please contact the Credentialing and Vendor Management Department at CCICredentialing@ConnectiCare.com to begin the process.

Fill in the form online.
Print the form.
Fax the completed form to 866-561-9260 or e-mail scanned document with signature to CCICredentialing@ConnectiCare.com or mail to ConnectiCare, Attn: Credentialing and Vendor Management, 175 Scott Swamp Road, Farmington, CT 06032-3124.
If you have any questions, call ConnectiCare’s Credentialing and Vendor Management Department at 866-610-8514.

Form

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Supply Reorder Form

If you are seeking to obtain:

Allergies or NKA Stickers.
Chart Stickers.
Maternity Precertification forms.
Member Education Cards.
Personal Care Plan Financial Waiver Forms.
Pregnancy Loss Notification Forms.
Provider Refund Forms.
Return Self-addressed mailing Labels.

Print the form.
Fill in the appropriate information.
Mail the completed form to ConnectiCare, Network Operations Department, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050 or fax to: 1-860-674-2849.
If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

Form

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W-9 Request for Taxpayer Identification Number and Certification

If you are seeking to change your Tax ID#.

Print the form.
Complete the W-9 Form and Provider Change Form.
Fill in the appropriate information.
Mail the completed forms to ConnectiCare, Network Operations Department, 175 Scott Swamp Road, PO Box 4050, Farmington, CT. 06034-4050 or Fax to: 1-860-674-2849.
If you have any questions, call Provider Services at 1-800-828-3407, Monday through Friday 8:00 a.m. – 5:00 p.m., Eastern Time.

Providers

Headlines

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Provider Online Forms