General
Forms |
Description |
Claim Review Note: Review each form to determine the appropriate form to use Additional Information Form |
Fillable |
Fillable - Submit form to: |
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Interactive |
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Interactive |
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Interactive |
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Interactive |
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Out-of-Network — Enrollee Notification Form for Regulated Business (Use this form if "TDI" is on member's ID card) | |
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PPO Notification for non pre-cert surgeries per Texas Administrative Code 3.3703 |
Fillable |
Prior Authorization - Standard Health Care Services Prior Authorization Form |
Fillable |
Fillable |
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Fillable |
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Recommended Clinical Review Form – Outpatient Services (formerly the Predetermination of Benefits form) |
Fillable |
Fillable |
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Fillable |
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Verification Of Benefits Processing and Request Form |
Verification of Benefit Form Interactive |