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RMHP: Rocky Mountain Health Plans

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Commonly Used Forms

Provider Information Update/Change Form

CAQH Data Form

PCP Assignment/Change 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

Check Refund Form

Medicare Billing Guide

Prescription Claim Form (Medicare Part D Members only)

Prescription Claim Form (Commercial and Medicaid Members only)

Prescription Claim Form (PERA & IBM)

EDI

EDI Transaction Request Form

Pharmacy

Medicare Part D Formulary Exception Request Form

Medicare Part D Tier Exception Request Form

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

Med 178 - Medicaid Sterilization Consent Form


 
 
Rocky Mountain Health Plans