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Forms / formulary

Formulary

Medicaid list of covered drugs (Formulary) – effective 3/1/2022 (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) 

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

Intensive care management (ICM) referral

MN Restricted Recipient Referral (MRRP) Program medical referral


Behavioral Health

  • Diagnostic assessment (PDF)
    Download
  • Mental health TCM notification form (PDF)
    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 (PDF)
    Download
  • W-9 for non-contracted providers (PDF)
    Download

Contracting and credentialing

  • Disclosure of ownership changes form (PDF)
    Download
  • Facility credentialing application (PDF)
    Download
  • Location add/term/change form (PDF)
    Download
  • Location and practitioner roster template (XLS)
    Download
  • Practitioner initial credentialing application (PDF)
    Download
  • Practitioner re-credentialing application (PDF)
    Download
  • Practitioner add/term/change form (PDF)
    Download
  • Quarterly complaint form (DOCX)
    Download

Pharmacy

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

Service authorizations

  • Continuity of care (PDF)
    Download
  • Inpatient admissions notification (PDF)
    Download
  • Partnered provider out-of-network referral (PDF)
    Download
  • Service authorization request (PDF)
    Download
  • Service authorization request form for ARHMS, IRTS and ACT services (DOC)
    Download
  • Substitute health service request form (PDF)
    Download

Provider updates

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Provider updates

Electronic transaction guidelines

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