Rocky Mountain Health Plans

Commonly Used Forms

Provider Information Update/Change Form

CAQH Data Form

Claims Management

Claims Action Request (CAR) Form

Provider Dispute Resolution Form

Injury Information Form

Fax Cover Sheet (for submitting records)

CMS 1500 Claim Form

UB-04 Claim Form

Medicare Billing Guide

Prescription Reimbursement Form (Medicare Part D Members only)

Prescription Claim Form (Commercial and Medicaid Members only)

EDI

EDI Transaction Request Form

Pharmacy

Utilization Review

UM Preauthorization Form

Home Health Authorization Form

DME Authorization Form

Pharmacy Preauthorization Forms

BIPAP/CPAP Questionnaire

Waiver of Liability/Advanced Beneficiary Notice Form

Pregnancy Notification/Procedure Form

Notice of Medicare Provider Non-Coverage

Notice of Discharge & Medicare Appeal Rights

Med 178 - Medicaid Sterilization Consent Form