Documents and Forms

The Provider Manual has everything you need to know about member benefits, coverage, and provider guidelines. Click the link below to view or save a copy.

• Provider Manual - (PDF)
• Claims Manual - (PDF)

• Primary Care Provider Reassignment Form - (PDF)
• Care Coordination/Complex Case Management Referral Form - (PDF)
• MSA-1302 Beneficiary Monitoring Primary Provider Referral Notification/Request Form - (PDF)
• Inpatient Prior Authorization Form (PDF)
• Outpatient Prior Authorization Form (PDF)

Mental Health Forms:

• Behavioral Health Discharge Transition of Care Form - (PDF)
• Outpatient Psychological Testing Authorization Request Form - (PDF)

Medical Records & Data Forms:

• Data Exchange Request Form - (PDF)
• Electronic Medical Request Form - (PDF)

Diabetic Medical Supply Form:

• Healthy Living (Diabetic) Medical Supply Form - (PDF)

COPD Home Program Form:

• COPD Home Program Referral Form - (PDF)

Sterilization Informed Consent:

• Informed Consent to Sterilization - (PDF)

Maternal Infant Programs:

• Maternal Infant Health Programs - (PDF)

Community Health Workers (CHWs) Information:

• MI CHW and SDoH Provider Resource - (PDF)

Provider Notification of Pregnancy Assessment Form (PDF)

About the Notification of Pregnancy Program (PDF)

Frequently Asked Questions:
Notification Of Pregnancy (NOP) for Maternal Infant Health Programs (MIHP) Providers (PDF)

Patient Communication Assessment Tool (PDF) - This tool is meant to help deaf, hard-of-hearing, late-deafened, deaf-blind, low/no vision, close vision, minimal-language, and/or speech loss patients receive effective communication via individual communication modes that best suit their needs.

• HEDIS® Quick Reference Guide 2023 - (PDF)
• Provider Incentive Guidebook 2023 - (PDF)

Attestation Forms

• Well-Care Visit Form (PDF)
• Women's Care Form (PDF)
• Diabetes Care Form (PDF)
• Prenatal and Postpartum Care Form (PDF)

Exclusion Forms:

• Breast Cancer Screening Exclusion Form - (PDF)
• Cervical Cancer Screening Exclusion Form - (PDF)
• Diabetes Exclusion Form - (PDF)

P4P/PCMH Program:

• Pay for Performance Program (P4P) - (PDF)
• PCMH Incentive Program - (PDF)

Links:

• Alliance for Immunization in Michigan (AIM)
• CDC Immunization Schedules
• Centers for Disease Control and Prevention

Healthy Michigan Plan beneficiaries are encouraged to work in collaboration with their health care provider to establish annual health goals. The Healthy Michigan Plan HRA should be completed by member and provider together and faxed to the health plan at 833-341-2052. For a HRA to be considered complete the provider must complete all of section 4. Please visit the MDHHS Health Risk Assessment for HRA resources and templates.

MDHHS Health Risk Assessment Website

• Adverse Events Reporting Form - (PDF)

 Primary Care Provider Uplift - Payment Review Action Request Form 

Request for Claim Dispute Form (Dates of Service 3/31/2022 and before)

Request for Claim Dispute Form (Dates of Service 4/1/2022 and after)

Links:

• Information for Medicaid Providers (From MDCH.gov)

• MAHP Credentialing Application - (PDF)

Links:

• CAQH Credentialing Application

• Michigan Regulatory Requirements Manual - (PDF)

• Meridian's Advance Directives Information - (PDF)

• Critical Incident Form - (PDF)
• MI Reporting Grid - (PDF)