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Forms / formulary

Formulary

Medicaid list of covered drugs (Formulary) – effective 3/1/2023 (PDF)

List of covered drugs for SNBC members with Medicare coverage (Formulary) - effective 4/1/2022 (PDF)

Forms

Advance recipient notice of non-covered service/item (PDF)

Care management referral  

HCBS waiver / AC and ECS case management transfer (PDF)


Behavioral Health

  • Mental health TCM notification
    Download

Claims and payment

  • Automated clearinghouse ACH funds transfer request
    Download
  • Claims adjustment reconsideration request
    Download
  • Client placement authorization (PDF)
    Download
  • W9 for contracted providers
    Download
  • W-9 for non-contracted providers (PDF)
    Download

Contracting and credentialing

  • Contracted provider forms
    Download
  • Non-contracted provider forms
    Download
  • Disclosure of ownership changes form (PDF)
    Download
  • Facility credentialing application
    Download
  • Health services checklist (PDF)
    Download
  • Location add/term/change
    Download
  • Location and practitioner roster template (XLS)
    Download
  • Practitioner initial credentialing application (PDF)
    Download
  • Practitioner re-credentialing application (PDF)
    Download
  • Practitioner add/term/change (PDF)
    Download
  • Quarterly complaint
    Download

Pharmacy

  • Prescription drug reconsideration request
    Download
  • Prescription drug prior authorization form (PDF)
    Download

Service authorizations

  • Behavioral health home (BHH) notification (PDF)
    Download
  • Clinical trial attestation (PDF)
    Download
  • Continuity of care
    Download
  • Inpatient admission notification
    Download
  • IRTS extension (more than 90 days)
    Download
  • MN Restricted Recipient Program (MRRP) medical referral
    Download
  • Nursing facility communication (DHS form)
    Download
  • Partnered provider out-of-network referral
    Download
  • Service authorization request
    Download
  • Substitute health service request
    Download

Provider updates

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Provider updates

Electronic transaction guidelines

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