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Forms and Documents

If you need a copy of a particular form, ConnectiCare's online form resource can save you time. 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

  • Claim Resubmission Request Form

    Provide the required information to process your request for an adjusted or corrected claim.

  • Claim Status Request Form

    Request claim status.

  • Electronic Funds Transfer Authorization

    Request payment directly into your bank account on the same day we issue a reimbursement check.

  • Provider Appeal Request Form

    Request reconsideration of a claim that was denied for administrative purposes (e.g., filing limit, coding edits).

  • Standard Provider Refund Form

    Refund ConnectiCare for an overpayment.

  • Claim Submission for Unlisted Procedure or Service Code

    Submit a claim with unlisted CPT code(s) and/or unlisted services. Please refer to our Unlisted Procedure Codes Reimbursement Policy for our complete billing guidelines.
 

Medical Preauthorization

  • Clinical Review Preauthorization Request Form

    Request authorization of services or procedures included under ConnectiCare’s preauthorization requirements.

  • Infertility Treatment Form

    Information needed for preauthorization request for infertility therapy, including infertility prescription drugs.

  • Out-of-Network Clinical Review Preauthorization Request Form

    Request authorization of services or procedures by out-of-network providers. 
 

For Massachusetts Providers Only

Submit preauthorizations for select imaging procedures to NIA/Magellan via the following:

RadMD web portal at radmd.com

NIA Call Center at 877-607-2363

Fax to 888-656-6648

  • Cardiac Imaging Preauthorization Form

    Request preauthorization for Myocardial Perfusion Imaging (MPI), Stress Echocardiogram or Multiple Gated Acquisition Scan (MUGA) services.

  • PET CT Preauthorization Form

    Request preauthorization for PET or PET CT imaging services.

  • CT/CTA/MRI/MRA Preauthorization Form

    Request preauthorization for CT, CTA, MRI, or MRA imaging services.

  • Psychological and Neuropsychological Assessment Supplemental Preauthorization Form

    Request preauthorization for psychological and neuropsychological assessment supplemental services.

  • Repetitive Transcranial Magnetic Stimulation Preauthorization Form

    Request preauthorization for repetitive transcranial magnetic stimulation services.
 

Pharmacy Preauthorization

  • Pharmacy Preauthorization Form: General Requests

  • Pharmacy Preauthorization Form: Massachusetts Preauthorization Requests Form

 

Other Forms

  • Provider Checklist: Items Needed to Process Appeals

  • Advance Health Care Directives

    Provide your patients with information on how to create an advance directive. 

  • Disabled Dependent Form

    Request continuation of ConnectiCare health care coverage on behalf of a disabled ConnectiCare dependent who has reached the maximum dependent age limit.

  • Health Delivery Organization (HDO) Form

    Updated July 2022

    All ancillary applicants requesting to participate within the ConnectiCare network of participating health care providers.

  • Provider Credentialing Form

    Apply to be part of the ConnectiCare network of participating health care providers or update your demographic information.

  • Provider Demographic Change Request Form

    Update your demographic information.

  • W-9 Request for Taxpayer Identification Number and Certification

    Change or update your tax ID#. 

  • Non-Participating Provider Advance Member Notification Form

    Explain why you are referring a ConnectiCare member to receive services from a non-participating physician, facility, or other health care provider.
 

Claims Payment

  • Medicare Claim Submission for Unlisted Procedure Codes

    Submit a claim with unlisted CPT code(s) and/or unlisted services. Please refer to our Unlisted Procedure Codes Reimbursement Policy for our complete billing guidelines.

  • Medicare Provider Appeal Request Form

    Request reconsideration of a claim that was denied for administrative purposes (e.g., filing limit, coding edits). 

  • Medicare Standard Provider Refund Form

    Refund ConnectiCare for an overpayment.
 

Medical Preauthorization

  • Clinical Review Preauthorization Request Form

    Request authorization of services or procedures included under ConnectiCare’s preauthorization requirements.

  • Medicare Out-of-Network Clinical Review Preauthorization Request Form

    Request authorization of services or procedures by out-of-network providers. 

  • Medicare Organization Determination Reopening Request Form

    Provide supporting information for a Medicare reopening request.
 

Pharmacy Preauthorization

  • Addition to Formulary Request Form

    Request to add a drug to ConnectiCare's formulary. 

  • Request for Medicare Prescription Drug Coverage Determination Form

    Request coverage for a specific medicine that is not currently covered under a member's plan.

  • Medicare Reconsideration Request Form

    Ask for reconsideration if denied a request for Medicare prescription drug coverage determination.
 

Other Forms

  • Provider Checklist: Items Needed to Process Appeals

  • Advance Health Care Directives

    Provide your patients with information on how to create an advance directive. 

  • Home Delivery Organization (HDO) Form

    Apply to be part of the ConnectiCare network of participating health care providers or update your demographic information.

  • Provider Credentialing Form

    Apply to be part of the ConnectiCare network of participating health care providers.

  • Provider Demographic Change Form

    Update your demographic information.

  • W-9 Request for Taxpayer Identification Number and Certification

    Update your tax ID#. 

  • Non-Participating Provider Appeal Waiver of Liability Form

    Affirm you will not bill a member for services provided that were denied coverage under their ConnectiCare plan.
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©2021 ConnectiCare. All Rights Reserved.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.