Add new data or change originally submitted data on a claim
- Claim Adjustment Request - fax
- Claim Appeal Form - fax
- Dental Claim Attachment - fax
- Medical Claim Attachment - fax
Contracting, Credentialing and Enrollment
- Join our network
- Online Credentialing submission
- Check the status of a new credentialing application
- Minnesota Uniform Credentialing application
- MTM credentialing application
- Initial Dental Credentialing application
- Disease, Case and Lifestyle Management
- Hospital Admission/Discharge
- Hospice Communication form
- Medical Practice Guidelines
- Minnesota Rare Disease Intake form
- Never Event Reporting
- Restricted Recipient Program (RRP) provider referral
- Self Reported Complaints
- Site Survey
Forms for submitting prior authorization requests
Sign in to check the status of your prior authorization request and select Authorizations and referrals from your menu.
Fillable forms work best when using the Adobe Acrobat Reader DC application. Visit get.Adobe.com/reader for more information.
- Airway Clearance System/Chest Compression Generator System review
- CPM review
- DHS Nursing Facility (NF) Communication Form DHS-4461
- Durable Medical Equipment (DME) review
- Enteral Nutrition (Formula) review
- Enteral Nutrition (Formula) review - Minnesota Health Care Programs
- Fixed Wing Air Ambulance Transportation review
- Genetic Testing review
- Home Health Care review
- Hospital Bed review
- In-Network Benefit review
- Lift Chair review
- Medical-Dental Procedures - Accidental Dental review
- Medical-Dental Procedures - Facility-General Anesthesia review
- Medical-Dental Procedures - Oral Surgery for Dental Conditions review
- Medical-Dental Procedures - Orthognathic Surgery review
- Medical-Dental Procedures - Surgical Intervention for TMD review
- Medical gender services/surgery review
- Mental Health Partial Hospitalization review
- Mental Health Residential Treatment Services review
- PCA Assessment review
- PCA Change of Vendor review
- Pneumatic Compression Devices review
- Procedures review
- Radiofrequency Ablation Spine review
- Sacroiliac (SI) injections to treat SI joint pain review
- Site of Service-Attended Polysomnography for Evaluation of OSA review
- Skilled Nursing Facility Admission review
- Skilled Nursing Facility Continued Stay review
- Specialty Mattress Gp I or Gp II review
- Spinal Cord Stimulator review
- Spinal Fusion-Lumbar review
- Synagis (RSV) Season review
- Substance Use Disorder Services review
- Transcranial Magnetic Stimulation review
- Transplant Prior Notification review
- UnityPoint In-Network review
- Upper airway, hypoglossal nerve stimulation therapy for obstructive sleep apnea review
- Varicose vein procedures of the lower extremities review
- Weight Loss Surgery review
- Wheelchair review
Forms for dental services and requests
- Clinic address change form
- Initial Dental Credentialing application
- Dental Provider Change Notice
- Dental Procedures - Accidental Dental review
- W-9 form for Tax Id Changes
- Prior Notification of Diabetes or Pregnancy
- Provider Notification for HPCare Add'tl Prophys
Forms for pharmacy services and requests
- Cell and Gene Attestation form - Hemophilia A
- Cell and Gene Attestation form - Hemophilia B
- CMS standard format/CCD creator
- Disease, Case and Lifestyle Management
- Hepatitis Medication Request
- Minnesota Uniform Prior Authorization and Formulary Exception
- MTM credentialing application
- New Drug Request
- Prior Authorization / Exception
- Member / Patient
- Employer
- Broker
- HealthPartners Institute
