Standards
for Participation (15k)
Listing of credentials required to become a Health Plan Provider.
Practitioner's Rights (30k)
Information pertaining to Credentialing/Recredentialing, Standards for Participation
and Practitioner's Rights.
ER Contact Form
Fill out the appropriate fields online and click "Submit" when
finished.
Prenatal Risk Screen Form
Fill out the appropriate fields online and click "Submit" when
finished.
Users with Adobe Acrobat or Adobe Reader 7.0 or greater will be able to fill out the following forms below ONLINE by clicking on the fields or "tabbing" through the fields. Once the information is properly filled out, users then will click "Submit by Email". (Please note: if a field is required, the form will ask you to fill in the required pieces before sending or it will not go through).
If users do not or cannot have the the lastest Adobe Acrobat or Adobe Reader, they can scroll to the bottom of the forms and click on "Print Form". The form will be printed for the user to then manually fill out and return to Health Plan Provider Relations either by mail or fax.
Provider Update Form (139k)
Users will need to have the most recent version
of Adobe Acrobat or Adobe Reader (7.0 or greater).
Crisis Encounter Report Form (64k)
This form will aid the transportation of vital behavioral health information
from your facility to our Behavioral Health Unit. No preauthorization is
needed by the patient. Complete all appropriate information on the form and
fax completed form to The Health Plan Behavioral Health Unit at our local
fax: 740.699.6255 or toll free fax: 1.866.616.6255.
Users will need to have the most recent version of Adobe Acrobat or Adobe Reader (7.0 or greater).
Treatment
Continuation Request Form (686k)
This form is to be used for the Behavioral Health Unit. Users will need to
have the most recent version of Adobe Acrobat or Adobe Reader (7.0 or greater).
Psychological Testing Preauthorization REQUEST FORM (614k)
This form is to be used for the Behavioral Health Unit. Users will need to
have the most recent version of Adobe Acrobat or Adobe Reader (7.0 or greater).
All other forms can be printed, filled out appropriately, and sent to responsible party.
Patient Assessment Tool (37k)
Use in conjunction with prior authorization form for Customized Equipment,
Orthotics, and Prosthetics.
State
of West Virginia Credentialing Form (123k)
State of Ohio Credentialing Form (829k)
In order to read these files, you will have to have a copy of Adobe Acrobat Reader installed on your computer. If you do not, download and install the latest free version below.
Download Adobe Acrobat Reader.
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